Inquests (PFDs)

21/12/2023

2024-0032

Carrianne Franks

Nottingham City and Nottinghamshire Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England | UKHSA | National Institute for Clinical Excellence

NHS England,[REDACTED] UKHSA TB Unit, [REDACTED] National Institute for Clinical Excellence NHS England | UKHSA | National Institute for Clinical Excellence

Carrianne Franks died on 27 August 2021, at the Bassetlaw District Hospital, Nottinghamshire, as a result of Tuberculosis. She was a Flight Sergeant in the Royal Air Force Nursing Service. A coronial inquest into her death was opened on 21 July 2022. � An inquest before a jury concluded on 26 May 2023.

CIRCUMSTANCES OF DEATH � The Jury recorded the following salient conclusions on the Record of Inquest: � Carrianne was exposed to, and infected with, tuberculosis from a patient with active TB (smear positive) who was nursed on the Acute Assessment Unit of a London Hospital, where Carrianne was working as a nurse between 23 and 24 November 2020. � Carrianne was not an NHS employee, rather she had volunteered through the RAF to undertake a placement at an NHS hospital, to assist throughout the Covid-19 pandemic. � Carrianne was not classed by the hospital as a �close contact� of the infected patient, so she did not benefit from contact tracing, a warn and inform letter, or any education on the signs of TB infection to look out in the coming months. � By the time Carrianne became unwell with respiratory symptoms in June 2021, neither she, her GP, nor the RAF�s Occupational Health Department had been informed that she had been working on a hospital ward where a patient had tested positive for TB (smear positive). � It would have been of assistance to the doctors treating Carrianne to have known about her occupational proximity to a patient with active smear positive TB, as they would have conducted tests to seek to rule the condition in or out, and in this case, would have arrived at a diagnosis far sooner and in time to start treatment that would have prevented her death. � The lack of knowledge of her heightened risk of TB because of occupational exposure to a smear positive case, significantly delayed her diagnosis and treatment, which in turn contributed to her death.

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

Hospital Death (Clinical Procedures and medical management) related deaths

25/10/2023

2023-0396

Myra Maxfield

Stoke on Trent and North Staffordshire

NHS England; and University Hospital�s of North Midlands

On the 1st April 2022, I commenced an investigation into the death of Myra Maxfield.� The investigation concluded at the end of the inquest on 15th September 2023. The conclusion of the inquest was a short narrative conclusion of: �Complications following a fall on a background of natural causes� The cause of death was: 1a) Upper gastrointestinal bleed 1b) infected pressure ulcer following hip arthroplasty 1c) Fall II) Frailty of old age

i)�Myra Maxfield was a 89 year old lady who fell at her home address on the 7 September 2021. During the fall she sustained a fractured right hip. This required surgical intervention and this was carried out on the 9 September 2021. She recovered well from this, and was discharged to the Haywood Hospital, Stoke-on-Trent on the 18 September 2021. � ii)��During her stay at the Haywood Hospital she developed a pressure sore which developed eventually into a Grade 4 Pressure sore. � iii) On the 10 November 2021, she developed symptoms of an upper gastrointestinal bleed, and was taken to the Royal Stoke University Hospital, Stoke-on-Trent where an oesophageal gastro duodenoscopy was performed. She was discharged back to the Haywood Hospital on the 11 November 2021. � iv)�This hospital continued to treat the pressure ulcer, which developed until the 3 December 2021 when she was admitted to the Royal Stoke University Hospital, the pressure ulcer had progressed and she had osteomyelitis. She was treated until being discharged to the Haywood Hospital on the 23 December 2021. � v) She was treated there, and her pressure ulcer began to hea,l however, she deteriorated rapidly on the 11 March 2022 with a further upper gastrointestinal bleed. She was admitted to the Royal Stoke University Hospital, where she passed away on the 12 March 2022 as a result of the bleed, the fall and the pressure ulcers

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Myra Maxfield. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 | University Hospital�s of North Midlands

22/11/2023

2023-0462

Kathleen Booth

Staffordshire and Stoke on Trent

NHS England; � Royal Stoke University Hospital, Stoke-on-Trent

On the 7th July 2023, I commenced an investigation into the death of Mrs Kathleen Booth. The investigation concluded at the end of the inquest on 24 October 2023. The conclusion of the inquest was a narrative conclusion of complications following a fall. The cause of death was: � 1a) Stroke 1b) Fractured neck of femur 1c) Low blood pressure II) 4 day delay in operating on the fractured neck of femur

Mrs Booth had been admitted to hospital as an emergency following a fall in her own garden on 09 June 2023. She was transported by ambulance to the Royal Stoke University Hospital, Stoke-on-Trent. A hip x-ray confirmed� displaced� intra-capsular neck of femur fracture on the left. On Monday 12 June 2023, a decision was made to operate. The operation was due on the 12 June 2023 but was delayed until� the following day due to a large amount of trauma patients in the hospital. On� 13 June 2023, the surgery was performed and was uneventful. After surgery Mrs Booth was found to be alert and comfortable in the recovery area. Around 9pm, she suffered a sudden deterioration and passed away.

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

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

17/04/2024

2024-0203

Margaret Burman

Wiltshire and Swindon

NHS England����������������������������������������������������������� The Secretary of State for Health & Social Care

On the 26th of July 2021, I opened an Inquest into the death of Margaret Avril Burman. During the course of the Inquest final hearing, I was told by the family that Margaret preferred to be known by her second name, Avril, and I will be referring to her by that second name for the remainder of this report. � Avril died at Salisbury District Hospital here in Wiltshire on the 13th of July 2021. She was aged 88 years old. On the 5th of April 2024, I concluded Avril�s Inquest. I found the medical cause of death was as follows: � 1a. lntracranial Bleed 1b. Head Injury 1c. Fall II. Dementia, Atrial Fibrillation (on Anticoagulation) � I additionally recorded a short form conclusion of Accident and in response to the question as regards when, where and how (by what means Avril came by her death) I recorded in box 3 of the Record of Inquest as follows: � �Margaret, who preferred to be known by her second name Avril, died on 13 July 2021 at Salisbury District Hospital in Wiltshire as a result of an intracranial bleed. Avril had an unwitnessed fall at around 2130 on the ward during the evening on 6 July 2021 resulting in the head injury. Avril had a history of falls pre-admission and had dementia. Avril also had atrial fibrillation and was on anticoagulation which was being given to her at the time of the fall despite doctors� directions that it be stopped, given on 30 June 2021 and 1 July 2021. The Apixaban and the dementia more likely than not contributed to the severity of the bleed. The Falls Risk Assessment did not address the known falls risk which was high and there was� no enhanced care documentation, although Avril was in a ward bay where but for the non-availability of a Health Care Assistant that shift, would have been present and more likely than not would have avoided the severity of the injury by managing the fall.�

Avril had a history of falls and was admitted briefly to Salisbury District Hospital on the 26 th of June 2021 having had what was believed to have been an unwitnessed seizure. She was discharged the following day but then re-attended and was subsequently re-admitted on the 28th of June 2021 following a fall and possible long lie. There was concern that Avril had a urinary tract infection and she was prescribed appropriate antibiotics. Avril was also in receipt of Apixaban for atrial fibrillation and although there are notes on 2 occasions where a doctor has directed that the medication be stopped, however, this did not appear to happen before she was found having fallen on the ward on the 6th of July 2021. � As you will be able to see from what I have recorded in relation to the when, where and how in box 3 of the Record of Inquest, relevant risk assessment falls were not appropriately completed by nursing staff although I did accept evidence that Avril had been placed in a bay with a small number of other patients on Spire Ward with the intention that overnight there would be a Healthcare Assistant who would monitor specifically those patients in that bay and assist any patient who was found out of bed to either return to bed or for example be supported and assisted to the lavatory. Unfortunately, especially back in 2021 I heard that there� were significant staffing issues with staff off sick because of COVID and challenges in relation to temporary staff unwilling to provide additional support. As a consequence, the Healthcare Assistant was unavailable, and no replacement was secured for the overnight shift and consequently there was no person able to monitor the ward bay where Avril�s bed was located. Her fall was unwitnessed by staff and as a consequence of her fall, she sustained a traumatic head injury from which she died on the 13th of July 2021.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, � -Salisbury District Hospital Family of Avril � I am also under a duty to send the Chief Coroner a copy of your response . � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 | Department of Health and Social Care

19/02/2023

2023-0068

Stefan Kluibenschadl

North East Kent

NHS Kent and Medway Clinical Commissioning Group

On the 8th April 2022 I opened an inquest into the death of Stefan Kluibenschadl. At the inquest, which lasted two days and heard from a few of those involved in Stefan�s short life, I concluded on 1st December 2022 with a narrative conclusion �He died as a consequence of his own actions, his intention being unknown�

1.��Stefan suffered from autism and was at school at Laleham gap where he had been since April 2013. He had annual reviews of his placement at the school and was doing well and at the start of the winter 2020 term had managed to obtain a part time job and was considering career options of either the army or food industry. He had an extremely supportive family and parents who made significant efforts to ensure that he had access to the support he needed. � 2.�Both his parents and his school noted a decline in his mental health in December 2021 and he met with the school alongside his parents and his timetable was amended and steps to obtain additional support considered. On 14th January 2022 he told a member of staff at school that he had contacted the National Suicide Prevention helpline but later appeared to deny this. He apparently did not express any intent to harm himself but did express feelings of being low. 3. His parents, having tried to see what help was available locally, took steps to try to arrange private counselling and arranged for this to start after the February half term. The service the family approached did not consider Stefan was suitable for short term counselling and advice was given to approach his General Practitioner(GP). On 15th March 2022 Stefan�s Mum spoke to his GP and asked for a letter to apply for funding from specific autism related counselling which his GP did but this was rejected and the letter received on 17th March 2022. At the consultation which occurred on the telephone between Stefan�s mother and his GP there was no mention of suicidal ideation or self-harm. On Sunday 20th March Stefan was found hanging at home in his bedroom by his family and he was taken to hospital and subsequently transferred to Kings College hospital where sadly he died on 26th March 2022. 4. In the course of hearing the evidence it was clear that local mental health services were considered to be accessible via a Single Point of Access and that anyone could refer in this way and the healthcare provider would then screen any referral which was made and possibly provide treatment. However such a referral was not made for Stefan because it was not clear that this was available to Stefan�s family who would have taken whatever steps they could have done to ensure appropriate support. His General Practitioner was aware of the Single Point of Access and that there were groups available but waits for specific services for those with autism in her experience were at least 3 months and instead she referred him to a different service at South London and the Maudsley which she considered may better suit his needs. The referral was rejected but the correspondence on this only came to light after Stefan�s sad death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family, his GP and North East London 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.

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

NHS Kent and Medway Clinical Commissioning Group

27/11/2023

2023-0478

Glyn Ackerley

Cheshire

NHS Pathways, care of the Department for Health and Social Care.

On 08 September 2022 I commenced an investigation into the death of Glyn ACKERLEY aged 56. The investigation concluded at the end of the inquest on 22 November 2022. The conclusion of the inquest was that: Glyn Ackerley died after becoming unresponsive at home on 4 September 2022, the cause of which cannot be determined.

Glyn Ackerley had a number of health issues which necessitated him taking pain relieving medication including [REDACTED]. � On 4 September 2022 he reported to his wife that he had swallowed [REDACTED].and left the address. His wife telephoned for an ambulance (North West Ambulance Service) at 21.48 and the call was triaged as a category 3 response based on the NHS Pathways algorithm. At 22.37 the police called the ambulance service and advised that he was having difficulty breathing. The call was upgraded to a category 1 response and the ambulance arrived at 22.52 � The evidence was inconclusive as to whether Mr Ackerley had in fact swallowed [REDACTED] as he reported to his wife, with levels of [REDACTED]. found in his blood post mortem being consistent with both an overdose and the therapeutic range.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Ackerley�s family I have also sent it to North West Ambulance Service NHS 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.

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

12/01/2024

2024-0023

Iona Buckingham

Northamptonshire

NORTHAMPTON GENERAL HOSPITAL NHS TRUST NHS NORTHAMPTONSHIRE INTEGRATED CARE BOARD NHS ENGLAND

On 14th December 2022 an investigation was commenced into the death of Iona Grace Buckingham, aged 9 months. The investigation concluded at the end of the inquest on 10th January 2024. The conclusion of the inquest was a narrative conclusion: � Iona Buckingham died as a result of bronchopneumonia with empyema due to invasive Group A streptococcal infection. On 29 November 2022 there was a missed opportunity to administer clindamycin, an antibiotic, which possibly contributed to Iona�s death. On 3 December 2022 there was a further missed opportunity to (i) undertake an x-ray; (ii) administer clindamycin; and (iii) arrange for transfer to a tertiary centre for the purpose of undertaking a chest drain. These matters probably contributed to Iona�s death. Iona died during an accidental extubation on 4 December 2022. � The medical cause of death was: � 1a Bronchopneumonia with empyema due to invasive Group A streptococcal infection

On 28 November 2022 Iona Buckingham was admitted to the Northampton General Hospital for oxygen therapy and feeding support in view of a diagnosis of bronchiolitis. A chest x-ray was performed on 29 November 2022 which showed right upper lobe pneumonia and some pleural effusion. Iona was escalated from high-flow nasal cannula oxygen to continuous positive airway pressure (�CPAP�). � Iona continued to receive antibiotics and her condition appeared to improve. On 30 November 2022 she was stepped down from high-dependency care. � At or around 14.00 on 3 December 2022 Iona was reviewed. She was observed to be in distress and was struggling to breathe. Iona was upgraded to a higher level of respiratory support. She was to be reviewed later for a possible need to return to CPAP. � At or around 10.00 on 4 December 2022 a chest x-ray was performed. The x-ray showed a �whiteout� to the right lung and pleural effusion. Iona was moved to the High Dependency Unit where she returned to CPAP. � Attempts were made to insert an endotracheal tube (�ETT�). A further x-ray showed that the ETT was not properly located and therefore a decision was made to re-site it. In doing so, the ETT became dislodged. Iona went into cardiac arrest. � Despite attempts to resuscitate her, Iona died at 18.37 on 4 December 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � [REDACTED]���������������������������������������������� . � 2. Children�s Medical Emergency Transport, care of the Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Child Death (from 2015) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Northampton General Hospitals NHS Trust | NHS Northamptonshire Integrated Care Board | NHS England

03/09/2024

2024-0481

Margaret Aitchison

South Yorkshire East

National Care Consortium Ltd

On the 3rd January 2023 I commenced an investigation into the death of Margaret Aitchison. The investigation concluded at the end of the inquest . The conclusion of the inquest was:� Accidental death� 1a Multiple traumatic injuries 1b Fall 1c II Ischaemic heart disease and hypothermia

Margaret Aitchison was a resident in the Broom Lane Care home. Her room was on the first floor of� the Sitwell Unit. On the 15th December 2022 at around 10:30 p.m. there was a fire alarm activation.�� The fire service attended and established that it was a false alarm having being activated by one of� the residents. They departed and the maintenance worker came to reset the alarm. There was� conflicting evidence as to the resident checks carried out after the alarm had sounded and I found that there were either no or inadequate resident checks following the reactivation of the alarm and� furthermore some if not all the fire exits were not checked following the alarm. Although it is not clear� whether sleep checks were properly performed on a 2 hourly basis throughout the night, I was able to� determine is that at some time after 6:00 a.m. carers discovered that Mrs Aitchison was no longer in� her room and after a check of the premises which lasted up to 30 minutes, she was found at the� bottom of an unheated stairwell leading to an external fire exit. She had somehow accessed what� should have been a locked fire door on the landing area and having gone through, fell down the stairs� sustaining traumatic injuries from which she died. She was hypothermic when found (the outside� temperature was -5 degrees). I heard evidence that new systems are now in place for checking� resident safety and fire door exits after an alarm has sounded and the system has been reactivated�but one of the witnesses, who was a carer at the time of the incident and has remained at the home,� said that there were still no formal checks and matters hadn�t changed.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Ward� Hadaway, Rotherham Metropolitan Borough Council and Mrs Aitchison�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.

Care Home Health related deaths

National Care Consortium Ltd�| Pristine Care Group Ltd

31/01/2024

2024-0047

Guy Scotchford

Cornwall and the Isles of Scilly

National Crime Agency Department for Science, Innovation & Technology

On 7th July 2023, I commenced an investigation into the death of Guy Douglas Scotchford. The investigation concluded at the end of the inquest on 30th January 2024. � I recorded the cause of death as 1a) Asphyxiation My conclusion as to the death was as follows: Suicide

Guy Scotchford had a long history of mental health problems with chronic suicidal ideation and believed he was suffering from a condition called Mast Cell Activation Syndrome, something he had researched extensively. This impacted on his day-to-day health and well being. He had a complex past medical history to include depression, [REDACTED] addiction and chronic multi system, medically unexplained symptoms of unclear cause. There had not been a formal diagnosis of Mast Cell Activation Syndrome as there was minimal evidence to reach this but he was under specialist care provided by the Clinical Immunology Department at Derriford Hospital who were providing valuable advice and guidance to manage his symptoms. Guy had previously disclosed to his sister, GP and Mental Health Services that he had researched ways to end his life and at one stage stated he had a plan in place but that he did not intend to act on those plans. He had some contact with mental health services and engaged in 3 intervention sessions with Wellbeing Coaches in October 2022 following which he reported feeling better. His final contact with the Mental Health Connect team was on 15th May 2023 when he reported ongoing chronic suicidal ideation. He agreed to contact with his GP and a safety plan was discussed. A review was held with his GP on 31st May 2023 at which time his physical and mental health was discussed at length. There was no change in his chronic suicidal thoughts, and he was keen to explore treatment and support for his condition. He declined any referral for further mental health or psychology services at that time. � Guy contacted his sister on the telephone in the early hours of 1st July 2023 and his opening comment was that he loved her. She stated that she would call him later. On attempting to contact him later that morning she was unable to get a response and raised a concern for welfare. Police officers attended his home address and he was found deceased in the bath. His death was confirmed at 15:24 on 1 July 2023. His death was due to Asphyxiation. � Police Officers at the scene located a printed 60-page document at his home address titled �[REDACTED]� which had been printed from a website�[REDACTED]. Police enquiries confirmed that this company received and delivered an order and they also provided a copy invoice dated 28/04/2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Guy Scotchford�s family. � 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.

Suicide (from 2015) This report is being sent to: National Crime Agency

11/09/2024

2024-0500

Emma Harper

Manchester West

National Highways Salford City Council

On 10 May 2024 I commenced an investigation into the death of Emma Victoria HARPER aged 52. The investigation concluded at the end of the inquest on 09 September 2024. The conclusion of the inquest was Suicide, and the medical cause of death was: I a Blunt Force Chest Trauma I b I c II

The deceased had a complex mental health history with a number of suicide attempts and self-harm having occurred in the months leading up to her death. The most recent occurred on in March when she swallowed batteries and was admitted to Salford Royal Hospital for a period between 25 March 2024 and 12 April 2024. A subsequent attendance following ingestion of batteries occurred on 26 April 2024. On discharge from hospital on 12 April there were delays in being referred to an appropriate mental health team in the community. On 1 May 2024, the deceased presented at Salford Royal Hospital and underwent a mental health assessment with the mental health liaison team, this resulted in a low risk assessment despite the previous attempts to take her own life and a referral to Living well was made. A referral was made to the urgent assessment team on 2 May 2024 by staff at the listening lounge after it was reported by the deceased that she did not feel she could keep herself safe. On 3 May 2024 she was assessed and accepted by the Home Treatment Team and daily visits were arranged with a care plan being agreed. The deceased left home at some point from the evening of 3 May 2024 and was subsequently seen on CCTV at approximately 5:25 on 4 May 2024 walking towards the bridge under which she was found She was discovered below a footbridge on the M602 on 4 May 2024 having fallen onto a crash barrier at the side of the motorway from the bridge above and no signs of life were observed. Death was declared at 06:40. On the balance of probabilities, the deceased fell from the foot bridge above having intended to do so to take her own life. The injuries she sustained in the fall caused her death.

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

Road (Highways Safety) related deaths | Suicide (from 2015)

National Highways | Salford City Council

27/08/2024

2024-0477

Mason Portman

West Yorkshire (Western)

National Highways Company Limited National Traffic Operations Centre 3 Ridgeway Quinton Business Park Birmingham B32 1AF

On 22 December 2023 I commenced an investigation into the death of Mason John PORTMAN aged 21. The investigation concluded at the end of the inquest on 13 August 2024. The conclusion of the inquest was that: I found that the cause of death to be: � 1a. Multiple injuries I arrived at a conclusion of road traffic collision

At approximately 6.10am on 17/12/23, Mason John Portman, who was driver and sole occupant, lost control of his motor vehicle as he exited the slip road at junction 22 on the east bound carriageway to the M62, and collided with a wooden fence and road sign, prior to travelling across the moorland and towards the A672,where it collided with an unoccupied motor vehicle parked on the layby, before then tumbling across the A672 where it came to rest, causing him to sustain fatal injuries.� At post-mortem he was found to have taken cocaine (less than 0.10mg/L) and his blood alcohol was 211 mg/dL.

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

Road (Highways Safety) related deaths

National Highways

18/12/2023

2023-0530

Nuel-Junior Dzernjo

Suffolk

National Institute for Health & Care Excellence (NICE) Royal College of Paediatrics and Child Health HEALTH POLICY

On 11 April 2023 I commenced an investigation into the death of Nuel-Junior Kerlii DZERNJO aged 10. The investigation concluded at the end of the inquest on 30 November 2023. The conclusion of the inquest was that: � Narrative Conclusion The medical cause of death was confirmed as: 1a Varicella Zoster Infection 1b Immunosuppression 1c Steroid Therapy

Nuel-Junior Dzernjo was a ten year old boy who had been under investigation for a neurodegenerative condition having been noted to have seizures on an Electroencephalogram. There was no clear cause or diagnosis for the seizures but it was felt that he was suffering from electrical status epilepticus during slow-wave sleep. In November 2022 a decision was made to commence him on high dose steroids, a known consequence of which was immunosuppression. He developed signs of chicken pox on Friday 17 February 2023 and was brought to his community paediatric appointment on 20 February 2023 but not seen and assessed as he was known to have a contagious disease. He was seen later that day by a nurse at his general practitioner surgery and was seen and sent home. A later discussion between a general practitioner at the surgery and the community paediatrician led to a referral to the paediatric assessment unit at Ipswich hospital. The unit was busy and an appointment was not made until the following morning. By 11am on 21 February 2023 Nuel had deteriorated further and his parents had to support and carry him to the paediatric assessment unit arriving at 11.05am. Observations taken at 11.30am revealed he was pyrexial, tachycardic and tachypnoeic but the sepsis pathway was not followed. He was prescribed paracetamol at 12.15 and seen by a paediatric registrar who did not consider the sepsis protocol should be initiated as there was a clear cause for his symptoms i.e chicken pox. The plan was made to observe him, recheck his observations and if he had improved to send him home with oral Acyclovir. At 13.20 he remained pyrexial and tachycardic and his respiratory rate was still high at 32 and he was prescribed Ibuprofen. By 15.30 his temperature had come down and his heart rate had settled but was still high at 118, as was his respiratory rate at 29. He was also unable to mobilise having previously not being limited with his mobility. He was confused but this was considered to be his usual presentation due to his neurodegenerative condition. The doctor who planned to discharge him did not discuss him with a Consultant and was not aware he needed a wheelchair to leave hospital having had no issues with his mobility prior to the onset of his current viral illness. He was taken home by his parents and was unable to swallow his oral medication and took very little by way of fluids. He deteriorated the following day and collapsed shortly before 2pm. His parents called emergency services and police and paramedics attended. Despite attempts at resuscitation including in the emergency department at West Suffolk hospital he died later that afternoon. A post mortem revealed he had died as a consequence of Varicella Zoster.

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

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

08/11/2024

2024-0620

Imogen Heap

Blackpool & Fylde

National Institute for Health & Care Excellence [N.I.C.E.] Level 1A� City Tower� Piccadilly Plaza� Manchester� M1 4BT

The death of Imogen Heap, aged 17 years, at Blackpool Victoria Hospital was reported to me and I opened an investigation. An inquest was conducted which concluded on 16th July 2024. The medical cause of her death was:� 1a Cardiac arrest�� 1b Bradycardia following extubation 1c Propranolol toxicity�� In box 3 of the Record of Inquest I recorded as follows: Imogen Heap had previously been prescribed propranolol medication after being diagnosed� with anxiety and depression. On 31st October 2023, and at a time when she was low in mood,� she voluntarily ingested a very high quantity of propranolol, and a smaller amount of�prescribed fluoxetine and some paracetamol from around 4 pm that afternoon. She did so with� a view to ending her life, but at some point she reflected upon this and decided to call for help� at 16.10 pm that evening. Due to pressures on the ambulance service at that time, it was 19.57� when an ambulance arrived at her home, and after initial assessment was transferred to� Blackpool Victoria Hospital by 20.38. A number of ambulances were queueing outside of the� hospital due to the number of patients in the emergency department at that time. Imogen� remained in the ambulance. At 21.33 hours Imogen became hypotensive and vomited. It was at around 22.13 when she began to have some seizures, brought on by the toxic impact of the� medication she had ingested, and was taken into the hospital emergency department. Imogen� received advanced life support, her heart beat stabilised, and was transferred to the Intensive� Treatment Unit. Over subsequent hours, Imogen�s prognosis remained very concerning. She�was being actively treated. By the morning of 2nd November 2023, at around 10.00 am, it was� felt the propranolol medication had metabolised sufficiently for her to be extubated, following� which she quickly became agitated. A member of the nursing staff appropriately raised� concerns about her deterioration but before she could be re-intubated she became bradycardic and went into cardiac arrest. Despite intubation and advance life support, Imogen deteriorated� and died at 13.33 that afternoon. Extubated on 2nd November 2023, and at a time when she� was still likely to die, an unexpected and unusual reaction to extubation inadvertently� accelerated her deterioration.� The conclusion of the Coroner was a narrative conclusion which read: At a time when she was low in mood, Imogen Heap ingested a very large quantity of tablets, mostly prescribed propranolol medication, with a view to ending her life. Within a period of� around 2.5 hours of beginning to ingest the medication, she decided to telephone for help,� but by that time the extent of the overdose was going to prove fatal.

In addition to the contents of section 3 above, the following is of note: Propranolol is a drug used to treat medical conditions, including the physical effects of anxiety. It is in a class of medications known as beta blockers.�� It is believed that this drug can rapidly cause significant chemical damage to the heart when� taken in overdose; typical effects include profound bradycardia (slow heart rate), hypotension� (low blood pressure) and reduced electrical activity in the heart. It may lead to fatigue, reduced consciousness levels, confusion, hallucinations, seizures, and coma.�� Overdose symptoms are usually apparent within one to two hours of medication being ingested and may result in the rapid deterioration of a patient�s condition.�� During this inquest, I received evidence from, � [REDACTED], a Consultant in emergency medicine and major trauma. He had�been asked by me to conduct an independent review of the care Imogen had received. � [REDACTED], an experienced Consultant in critical care. She gave evidence�regarding the hospital Trust�s Serious Incident Investigation Report. Both of these doctors were in agreement that Propranolol is a drug which is widely prescribed and often to relatively young people reporting symptoms of anxiety, but that there can be an� under-appreciation of how toxic an elevated level of propranolol medication can be.� At the conclusion of the inquest, I explained in court that I planned to write a report to prevent future deaths. However, further to giving that indication, I became aware that in 2020, the� Healthcare Safety Investigations Branch [HSIB] (which later became Health Services Safety� Investigations Body [HSSIB] had in February 2020 published a report which concluded with the� following recommendation:� It is recommended that the National Institute for Health and Care Excellence reviews and� updates guidance on the use of propranolol in the treatment of anxiety and migraine, with particular reference to the toxicity of propranolol in overdose.� That report noted that it had been felt that for some time there had been a steady rise in the� number of propranolol prescriptions issued to NHS patients, and about the number of deaths reported was being linked to propranolol overdose.� I repeat the link to that report here:� Potential under-recognised risk of harm from the use of propranolol In response to their report, HSSIB received helpful responses from organisations including: � National Institute for Health & Care Excellence [N.I.C.E.] � Royal College of General Physicians � NHS England & NHS Improvement � Association of Ambulance Chief Executives

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � �� Family of Imogen Heap� � �� Chief Executive, Blackpool Teaching Hospitals NHS Foundation Trust I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the� release or the publication of your response by the Chief Coroner.� I also send a copy to the following organisations as I believe they may find it to be of interest: Royal College of General Physicians� NHS England� Association of Ambulance Chief Executives [A.A.C.E.]

Alcohol, drug and medication related deaths

National Institute of Health and Care Excellence

05/11/2024

2024-0600

Audrey Lambert

Manchester South

National Institute for Health and Care Excellence

On 28th May 2024 I commenced an investigation into the death of Audrey Margaret LAMBERT. The investigation concluded on the 14th October� 2024 and the conclusion was one of narrative: Died from the� complications of a deep vein thrombosis following an accidental fall and necessary surgery. The medical cause of death was 1a)� Pulmonary Thromboembolism 1b) Deep Vein Thrombosis II) Sub� trochanteric fracture right proximal femur (operated on)

Audrey Margaret Lambert had an accidental fall at her home address on� 25th March 2024. She was admitted to Stepping Hill Hospital and found�to have a fracture of the right proximal femur. She was operated on. Post operatively she was prescribed 28 days course of heparin. Subsequently she was cared for at Brinnington Hall. Her mobility was significantly� reduced and she required a hoist and the assistance of two to mobilise.� On 28th May she was found unresponsive in bed. A post mortem found� she had died from pulmonary thromboembolism due to a deep vein� thrombosis.

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

National Institute for Health and Care Excellence

03/04/2023

2023-0115

REDACTED

Blackpool & Fylde

Neil O�Brien Parliamentary Under Secretary of State Department of Health and Social Care c/0 Ministerial Correspondence and Public Enquiries Unit Department of Health and Social Care 39 Victoria Street London SWlH OEU United Kingdom � Claire Coutinho, Parliamentary Under Secretary of State Ministerial and Public Communications Division Department for Education Piccadily Gate Manchester M12WP � Dame Rachel de Souza Children�s Commissioner for England Sanctuary Buildings 20 Great Smith Street London SWlP 3BT

The death of [REDACTED] on 24th September 2022 at his home address was reported to me and I opened an investigation which concluded by way of an inquest held on 29th March 2023. I determined that the medical cause of death was 1 a Hanging In box 3 of the Record of Inquest I recorded as follows: [REDACTED] He was in the process of being assessed for autism but no diagnosis had yet been made. On Saturday 24th September 2022, and as his family were preparing their evening meal, [REDACTED] he [REDACTED] went up to his bedroom. [REDACTED] his Parents to enter the room where they found [REDACTED] unresponsive. [REDACTED] The [REDACTED] was not wrapped around the neck. [REDACTED], which fatally restricted his breathing and he had rapidly lost consciousness. Despite cardiopulmonary resuscitation efforts from his Father, a neighbour and paramedics he could not be revived and upon arrival at hospital his death was confirmed at 18.34. From the available evidence, [REDACTED] had not intended to end his life. In box 4 of the Record of Inquest I determined that [REDACTED] died due to: MISADVENTURE.

In addition to the contents of section 3 above, the following is of note: � At the time he died, [REDACTED] was in the early stages of an assessment process aimed at confirming if he had a diagnosis of autism. His Parents had long suspected he was different from their other children. � He had attended a review on 23/07/22 with a Consultant Paediatrician, but there was more work to be done. � His family feel that had he been assessed earlier, and a diagnosis made, they may have been more equipped to deal with [REDACTED] on his more challenging days. � The court was informed that he had waited around three years for assessment. This was immensely frustrating. His Parents regularly learned that young people perceived to be more challenging were added to the waiting list at a much later stage, and allocated a place higher up that waiting list, with the inevitable consequence that [REDACTED] assessment was further delayed. � In April 2022, there was finally some progress and they became aware that the assessment process was to commence, but as it turned out not in sufficient time for him to have been assessed, diagnosed, and for his Parents to be given the help they feel they needed to support him before he died. � In a witness statement provided for the inquest, [REDACTED] Father described some of his character traits including: � [REDACTED] was a very physical, affectionate child; � He was interested in the outdoors, nature, wildlife, arts and crafts. � He was making excellent academic progress; � He was very self-deprecating � He was a risk taker. � He was impulsive. � Although the assessment process was in motion by the time he died, his Parents remained of the opinion that once assessed, he would most likely have been diagnosed with Attention Deficit Hyperactivity Disorder [ADHD].

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

Child Death (from 2015) This report is being sent to: Department of Health and Social Care | Department for Education | Children�s Commissioner for England

24/08/2023

2023-0292

Gordon Rodger

Cumbria

Network Rail Infrastructure Limited

On 7 March 2023 I commenced an investigation into the death of Gordon Alexander John RODGER. The investigation concluded at the end of the inquest . The conclusion of the inquest was Suicide � 1a�� Multiple injuries consistent with being struck by a train

On Thursday 02nd March 2023 at 0714hrs British Transport Police were made aware that the driver of the 2C39 service travelling between Barrow and Carlisle had just reported seeing a human body in the Askam-in-Furness area of Cumbria. � The driver explained that he had earlier observed something in that area when travelling�between Millom into Barrow, around 0625hrs, but had been unsure what this was. Therefore, when travelling back through the Askam area he had decided to slow the train service down for a better look. On inspection he noted this was a body of a person.

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

Suicide (from 2015) | Railway related deaths This report is being sent to: National Rail Infrastructure Limited

27/11/2024

2024-0653

Kenneth King

Norfolk

Norfolk Community Health & Care NHS Trust (NCHC) Woodlands House Norwich Community Hospital Bowthorpe Road Norwich NR2� 3TU

On 20 November 2023 I commenced an investigation into the death of Kenneth George Willard KING aged 76. The investigation concluded at the end of the inquest on 26 November 2024. The medical cause of death was: 1a) Septic Shock 1b) Bilateral Leg Cellulitis 1c) 2)�Type Two Diabetes Mellitus, Hypertension The conclusion of the inquest was: Mr King died from septic shock due to bilateral leg cellulitis. His wounds were not always dressed in accordance with the recommended time scales.

Mr King had a significant medical history. He was referred to the Community Nursing Team in June 2023 due to a wound on his right ankle. Mr King was rereferred in July 2023 when he had three wound sites. He was seen and continued to receive assessment and dressings to his wounds in the community. At various times there were delays in Mr King being seen in accordance with recommendations sometimes by five or six days. Mr King was at times prescribed antibiotics. On 10 October 2023 blood tests were taken and Mr King�s inflammatory markers were significantly elevated. He attended hospital but then self-discharged. He returned to hospital the next day and was admitted. Following intravenous antibiotics he was discharged to Ambulatory care on 14 October 2023 and returned to hospital on a daily basis for intravenous antibiotics until 21 October 2023, (not attending on 20 October 2023) when he was discharged to community care with oral antibiotics for five days.� Mr King was not referred to the community nursing team. An urgent visit by community nursing was requested on 27 October 2023 when Mr King had signs of infection. On 28 October 2023 Mr King was triaged and seen that day and his dressings were changed. Mr King was seen on 31 October and on 5 November 2023 when his dressings were changed. Swabs were taken on 8 November 2023 when a huge amount of strike through was noted on the left leg and a moderate amount of exude green in colour present on the right leg. Evidence was heard there was a mild malodor. Mr King�s dressings were changed on the morning of 10 November 2023. Evidence was heard there was no malodor and no sign of infection on this occasion neither of which is referred to in the written records. A referral was made for increased visits. Later that day Mr King was admitted to Norfolk and Norwich University Hospital with cellulitis of both legs, being generally unwell and confused. Mr King�s condition continued to deteriorate and he died on 12 November 2023 from septic shock due to bilateral leg cellulitis.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � The Family of the Deceased � Fosters Solicitors, Legal Representative for the Family � Legal Services, Norfolk and Norwich University Hospital I have also sent it to � Department of Health and Social Care � Care Quality Commission (CQC) � HSSIB (Health Services Safety Investigations Body) � Healthwatch Norfolk � NHS ENGLAND & NHS IMPROVEMENT who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Hospital Death (Clinical Procedures and medical management) related deaths

Norfolk Community Health & Care NHS Trust

25/03/2024

2024-0167

Christopher Sidle

Norfolk

Norfolk and Suffolk NHS Foundation Trust Hellesdon Hospital Drayton High Road Hellesdon Norwich NR6 5BE

On 12 July 2023, I commenced an investigation into the death of Christopher Edward SIDLE aged 51. The investigation concluded at the end of the inquest on 22 March 2024. � The medical cause of death was: 1a)�������� Traumatic Brain Injury 2)���������� Schizophrenia � The conclusion of the inquest was: Mr Christopher Sidle threw himself out of a moving taxi and suffered fatal injuries. His state of mind at the time is not revealed by the evidence. There were missed opportunities to provide appropriate and timely care to Christopher and assessments carried out in respect of his mental health were inadequate.

Christopher Sidle had a diagnosis of paranoid schizophrenia in 2011. This was well controlled with medication for many years with short relapses in 2014 and 2021, being resolved following swift and effective intervention by mental health services. In March 2023, Christopher started to show signs of relapse and displayed symptoms following a pattern of those displayed in previous psychotic episodes, which increased over time. He was seen by primary services and referred to secondary services. � Following triage on 21 April 2023, by the Crisis Resolution Home Treatment Team (�CRHTT�) Christopher was returned to primary care. Christopher was referred again to secondary services and an assessment completed on 10 May 2023. Christopher said he had not been taking his medication for a month. Deterioration in Christopher�s mental health was recognised as the main risk and concordance with his medication needed to be achieved within three to four days. Christopher declined engagement with the CRHTT and said he would now take his medication. Christopher was allocated a Care Co Ordinator in the Community Mental Health Team on 17 May 2023 and was reviewed for several days to ensure medication concordance. These were exceptional steps taken by the Community Team due to concerns with regard to Christopher�s mental health. Christopher was again referred to the CRHTT on 19 May 2023 due to concerns regarding his mental ill health and displaying signs of psychosis and a pattern of previous psychotic symptoms. He was triaged and an assessment was undertaken on 20 May 2023. Christopher attended with his bag packed and was willing to be admitted for inpatient treatment. Evidence was heard this would not be possible in any event due to lack of available inpatient beds at that time. Christopher again said he was not taking his medication. Christopher was not taken on and again returned to the Community Team. The assessment was inadequate and psychotic markers were underestimated and/or missed. This was a missed opportunity to provide appropriate care and treatment to Christopher. Later that evening Christopher went missing from home and was later returned by police. From 22 May 2023, Christopher was monitored on a daily basis with regard to his medication for 7 to 10 days by the Community Team which they would not usually do, pending his being seen by a Consultant Psychiatrist. Christopher took his medication during this period. A recovery plan was completed and put in place by the Community Team by 1 June 2023, in which the crisis plan states: Deterioration in mental wellbeing � �It may be hard to notice, people should try to use their gut instincts, especially if they know me� and �Take over my responsibilities�, �Check my medication adherence� and �I may not know when help is needed and would appreciate teams making decisions.� Christopher agreed to see a Consultant Psychiatrist and to discuss a depot injection and was seen on 6 June 2023. A deterioration in his mental health was noted. Christopher declined depot injection and said he will take his oral medication. Christopher was seen by the Community Mental Health Team and arrangements were made for him to be seen in two to three weeks� time to review his medication. On 28 June 2023, Christopher showed psychotic symptoms witnessed by his family and then the community team and a referral was made to the CRHTT for possible admission to hospital. Christopher was accepting of the referral and was present when this was triaged. That evening Christopher went missing again and was returned home by police. Requests were made by his family for Christopher�s history and ability to mask his symptoms be recorded in his notes prior to the Crisis assessment. The assessment was carried out on 29 June 2023 without discussion within the team, without reading Christopher�s records other than the triage document and the previous assessment note, due to insufficient time being allowed by the Team prior to the assessment. The assessment continued without knowledge of Christopher�s history and his ability to mask symptoms. There was no formal monitoring of the assessment which was allocated on the basis of availability of assessor rather than experience or suitability. This was the assessor�s first lone assessment. Christopher was not taken on by the CRHTT and returned for community care. The assessment was inadequate and was a further missed opportunity to provide appropriate inpatient care to Christopher, which more than minimally contributed to his death. Following a telephone conversation with Christopher�s family again providing relevant information with regard to Christopher�s history and mental health, no further action was taken and the decision not to take Christopher on by the team remained. This was a further missed opportunity to provide appropriate care and treatment to Christopher. Concern was raised in the Community Team on the morning of 30 June 2023 that Christopher had not been taken on by the Crisis Team. No immediate action was taken to ensure Christopher was re-assessed and this was a missed opportunity to provide immediate appropriate care to Christopher. A Mental Health Act assessment was requested by Christopher�s family. A discussion by the allocated assessor with the community team was requested and this was not responded to. On 1 July 2023, Christopher ordered a taxi to take him to an acute hospital. En-route while the taxi was travelling at approximately 30 mph Christopher jumped out of the taxi into the roadway. Christopher was taken to Addenbrookes hospital where he was found to have suffered life threatening head injuries. Life sustaining therapies ceased on 4 July 2023 and Christopher died. The evidence does not reveal whether Christopher had intention or if so, what that intention was, at the time of jumping out of the taxi.

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

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

28/02/2024

2024-0112

Gillian Baumgardt

Avon

North Bristol Trust

On 20/12/22 an investigation was commenced into the death of Gillian Baumgardt. The investigation concluded at the end of the inquest on 27th February 2024. The conclusion of the inquest was � � �Mrs Baumgardt died in part because she underwent wrong site hip surgery due to multiple errors occurring in the performing and reporting of a plain x-ray of her hip�.

Mrs Baumgardt was an elderly lady with dementia who fractured her right hip at home. She was admitted to your hospital and diagnosed correctly with a suspected fractured right hip. � However, in then performing and reporting the plain x-ray of her hips the following errors occurred � Radiographer � Pre-exposure marker not placed in film field; Digital image inadvertently flipped; Digital image mislabelled left/right so that fractured side recorded as left; Cross on image denoting flipped not detected; Normal x-ray of left hip did not alert to error and did not lead to the affected side being double checked; Radiologist � Normal x-ray of left hip attributed to error in labelling, rather than alerting to error and leading to the affected side being double checked. As a result Mrs Baumgardt was referred to the orthopaedic team erroneously as presenting with a left hip fracture. Her age and dementia were such that she was difficult to assess clinically, the orthopaedic surgeons had no reason to suspect an error in labelling and she underwent surgery removing a healthy left femoral head. The error was then appreciated and she had to undergo surgery to the right fractured hip 2 days later. She died 6 weeks later having never regained her mobility. I found on the evidence that the wrong site surgery contributed to her death.

I have sent a copy of my report to the chief coroner and to Mrs Baumgardt�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 This report is being sent to: North Bristol Trust

02/05/2024

2024-0244

Karen Thomason

Cumbria

North Cumbria Integrated Care NHS Foundation Trust

On 8 November 2023 I commenced an investigation into the death of Karen THOMASON. The investigation concluded at the end of the inquest on 2nd May 2024. The conclusion of the inquest was Alcohol related death. The Medical Cause of death was: 1a Acute Ethanol Toxicity

Karen Thomason was 52 years old. She lived at in Carlisle, Cumbria. Ms Thomason was�alcohol dependent. She had been admitted to the Cumberland Infirmary, Carlisle on numerous occasions as a result of her use of alcohol. On any view Ms Thomason lived a �highly risky lifestyle� (as one of the treating clinicians described it in evidence). � Cumbria Housing staff had previously asked that Ms Thomason should not be discharged from hospital without them being notified. This was so that they could ensure that she did not arrive home without any support. � On 31st October 2023 Ms Thomason collapsed at home and was taken to hospital. She was discharged at 21:02 on 31st October. Cumbria Housing staff were not informed of her discharge. The next day, on 1st November 2023 Ms Thomason was found unresponsive at home. Her death was confirmed by ambulance staff at 12:03. Ms Thomason had consumed a substantial amount of alcohol, and this caused her death.

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

Alcohol, drug and medication related deaths This report is being sent to: North Cumbria Integrated Care

13/08/2024

2024-0447

Daphne Austin

Cumbria

North Cumbria Integrated Care NHS Trust

On 22 June 2023 I commenced an investigation into the death of Daphne Gillian AUSTIN. The investigation concluded at the end of the inquest on 8th August 2024. The conclusion of the inquest was a narrative. I found that the medical cause of death was: 1a Urosepsis and Acute Kidney Injury 1b 1c �II���Right cerebral Infarct

Ms Austin was 71 years old. She suffered from diabetes. On 22nd May 2023 Ms Austin was admitted to the Cumberland Infirmary, Carlisle. She had had a stroke. Whilst in hospital, Ms Austin�s glucose levels were poorly controlled. She also became dehydrated. Ms Austin�s fluid balance was not monitored in an effective manner. On 14th June 2023 it became apparent that Ms Austin had sustained an acute kidney injury. Blood testing was not carried out on 15th or 16th June, it is more likely than not that this was because of industrial action by junior doctors. On 17th June 2023, Ms Austin�s condition deteriorated and it became apparent that she had developed sepsis. Despite treatment, Ms Austin died as a result of that condition on 18th June 2023. Neglect (being the ineffective monitoring of Ms Austin�s fluid balance and the fact that blood testing was not carried out on 15th or 16th June 2023) contributed to Ms Austin�s death.

I have sent a copy of my report to the Chief Coroner and to the family of Ms Austin. I� have also sent it to the Secretary of State for Health and the British Medical Association who may find it useful or of interest given the potential national aspects of these� concerns. �� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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

North Cumbria Integrated Care NHS Trust

07/12/2022

2023-0031

Joan Ferguson

Newcastle upon Tyne and North Tyneside

North East Ambulance Service NHS Foundation Trust

On 10 May 2022 I commenced an investigation into the death of Joan Alison FERGUSON. The investigation concluded at the end of the inquest . The conclusion of the inquest was Joan Alison FERGUSON died at the Royal Victoria infirmary, Newcastle upon Tyne on 5th May 2022 of acute chronic congestive cardiac failure due to biventricular cardiac hypertrophy and an open fracture of her left tibia/fibula and distal femur. She had been discharged home following a short hospital admission at North Tyneside General Hospital. She had super morbid obesity and required ambulance transfer. During transfer on 3rd May 2022, she fell in the ambulance and sustained an open fracture to her tibia/fibula and a fractured left femur requiring surgical repair which was carried out the same day. She did not survive the consequences of her injuries in light of her comorbidities. 1a Acute on Chronic Cardiorespiratory Failure 1b Biventricular Cardiac Hypertrophy and Open Fracture of Left Tibia/Fibula and Distal Femur (operated on 03/05/22) 1c Morbid Obesity, Type 2 Diabetes Mellitus, Hypertension, Cor Pulmonale, Mitral Stenosis and Liver Cirrhosis

64yr female Recent NTGH admission with constipation, AKI and increasing oxygen requirements was being discharged home falling getting out of ambulance (DNACPR in place) open right tib/fib+distal femur # Significant Co-morbidity 1.� Super Morbid Obesity ~130kg 2.� OHS/ OSA CPAP intolerant, possible COPD, Home Oxygen 3.� AF, HTN, Pul HT RV dilation severe biatrial dilatation , mitral stenosis (2019) 4.� DM � Family attended ED as probable un-survivable injury given co-morbidity. Theatre GA and splinting of # with tibial nail and femoral retrograde nail, for analgesia and as open # L3 post op ventilated on high CVS support Nad/Ad Following morning woke and extubated onto HFNC, unfortunately no sig improvement in CVS support Deteriorated overnight with retained secretions, respiratory distress Fentanyl started Family attended and HFNC / pressor stopped Discussion with paramedics transport team Deborah (Investigating) , Coroners. Family very happy with care at RVI and opportunity to have time with Joan.

i have sent a copy of my report to the Chief Coroner [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.

Emergency services related deaths (2019 onwards)

North East Ambulance Service NHS Foundation Trust

01/08/2024

2024-0420

Stephen Lindsay

Cumbria

North East and North Cumbria Integrated Care Board

On 6 March 2024 I commenced an investigation into the death of Stephen LINDSAY. The investigation concluded at the end of the inquest . The conclusion of the inquest was� Death by suicide. 1a Hanging 1b 1c �II

Mr Lindsay was 71 years old. He lived in Cockermouth, Cumbria. In October 2023 Mr� Lindsay was diagnosed with metastatic Oesophageal Cancer. He experienced a number of complications associated with his diagnosis and was in pain. �� In November 2023 Mr Lindsay reported to his GP that he felt overwhelmed. In January 2024 Mr Lindsay had a procedure at the Royal Victoria Infirmary, Newcastle. The RVI�Mental Health Team (operated under the aegis of Cumbria, Northumbria, Tyne and Wear� NHS Foundation Trust (�CNTW�)) subsequently wrote to Mr Lindsay�s GP noting concerns about his mental health and suicidal ideation and noting that the efficacy of�antidepressant medication should be �monitored by services supporting Steven locally�. �� Mr Lindsay�s GP referred him to the local Community Treatment Team run by CNTW. On� 21st February 2021 that team responded: �This is a very sad situation and must be very� difficult for Stephen. I am sorry that CTT are not a service that can offer the interventions� that are needed at this stage. I am surprised that palliative care/McMillan team don�t have� staff that can help Stephen understand the diagnosis and prognosis. I am sorry that I can�t be anymore help�. � � Mr Lindsay died on 28th February 2024. I concluded that his death was suicide.

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

Mental Health related deaths � This report is being sent to: North East and North Cumbria Integrated Care Board

09/01/2024

2024-0018

Andrew Rees

Avon

North Somerset Council (via their instructed solicitors, Clyde & Co) Boatfolk Marinas Ltd

On 24th February 2023 an investigation was commenced into the death of Andrew James Rees. The investigation concluded at the end of the inquest on 9th January 2024. The conclusion of the inquest was: Accident The Cause of death was recorded as: 1a) Immersion in water

Mr REES consumed very high levels of alcohol on a night out with friends on 3rd February 2023 which impaired his motor control when walking home severely intoxicated. His route home was alongside an unguarded part of Portishead Marina from which his body was later retrieved. He died at Portishead Marina Portishead North Somerset due to immersion in water

I have sent a copy of my report to the chief coroner and to the following interested persons: The Rees 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.

Other related deaths This report is being sent to: North Somerset Council | Boatfolk Marinas ltd

10/04/2024

2024-0192

Paul Dow

Manchester North

North West Ambulance Service (NWAS) Secretary of State for Health and Social Care

On the 5th June 2023, I commenced an investigation into the death of Paul Dow, date of birth 25th August 1957 who died on the 3 April 2023 at the Royal Oldham Hospital The medical cause of his death was confirmed as 1a) Combined drug toxicity 2) lschaemic heart disease, Type 2 diabetes mellitus, urinary tract infection.

CIRCUMSTANCES OF DEATH On 28th�March 2023 Mr Dow was arrested and charged with criminal offences. On 29 March he was bailed subject to conditions not to go within 100 metres of his home address where he lived with his partner, as a result of which, he started staying at the Travelodge, Rochdale. Mr Dow was on his own in a room at the Travelodge when at 18.35 on 2 April 2023 he made an emergency call to the ambulance service . He made contact with a call handler employed by NWAS. He reported that he was a type 2 diabetic and said �I�ve taken a pile of tablets and I mean a pile� when asked whether this was an attempt to take his life he replied, �Well yeah, possibly.� He was asked what he had taken and he said he had taken�[REDACTED]. When asked whether he had taken a lot, boxes of each he replied �yeah.� He said he felt weird. Mr Dow was told there were delays of over an hour and a half in dispatching an ambulance. The call was coded as a category 3 response defined as 9 out 10 responses within 120 minutes. A clinician from the clinical hub attempted to call Mr Dow but received no response to calls at 19.09, 19.22 and 19.25. Mr Dow called the ambulance service again at 19.38 and� spoke to the same� call handler. He� said �I�ve taken loads� of tablets� the ones I� have form�� diabetes.� He was� asked again� whether� this was an attempt to take his life and said �I don�t know, could be.� This call was also coded as category 3. An ambulance arrived on scene at 20.27. Mr Dow stated to the paramedic that the overdose was intentional as he wanted to take his own life. Mr Dow was transported to hospital arriving at 21.43. Attempts to resuscitate him were unsuccessful and his death was confirmed on 3 April 2023.

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

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

21/07/2023

2023-0272

Steven Duquemin

Blackpool & Fylde

Northern Care Limited, trading as �ubu� Chief Operating Officer Windsor House, Cornwall Road, Harrogate, North Yorkshire HG1 2PW

The death of Steven Duquemin on at his home address was reported to me and I opened an investigation, which concluded by way of an inquest held on 28th June 2023. � I determined that the medical cause of Mr. Duquemin�s death was : � 1 a Asphyxia 1 b Airway obstruction 1 c Inhalation of food material � In box 3 of the Record of Inquest I recorded as follows: � Steven Duquemin had a diagnosis of autism, epilepsy and what has been described as a mild to moderate learning disability. He has previously presented with depression and associated psychotic symptoms. Having last been seen in his flat at shortly after 8 pm on 28th August 2022, Steven Duquemin was found unresponsive in his chair in his flat at shortly after 9 am on 29th August 2022. He had been deceased for a number of hours. A subsequent post mortem examination revealed that he had been eating raw chicken at some point overnight when a significant piece of which had become stuck in his airway, that he began to choke, and he suffered a fatal lack of oxygen to the brain. Steven resided in accommodation which is a community � based, domiciliary � type property where personal care and support are provided for vulnerable people living independently. He received help with aspects of his daily care during the day, and overnight he could seek assistance from a member of staff residing elsewhere in the building should he need to. The risk that Steven could choke on his food had not been fully appreciated, but from the available evidence it cannot be established that a fuller appreciation of the risk would have averted Steven�s death. � The conclusion of the Coroner was that Stephen died an Accidental death.

In addition to the contents of section 3 above, the following is of note: � ��� Steven Duquemin was a vulnerable man who died at a relatively young age. ��� During the day he had carers with him as he ate. He was at risk of choking and could eat erratically, even to the extent he may try to ingest non � food items. ���At some point overnight he tried to ingest a large piece of raw chicken and choked. He could access food from his fridge at a time when no care staff were present. ���He was not checked upon overnight � something a Service Manager told the court should have happened, but it cannot be said this would have altered the outcome. ���The location of the flat in which Steven lived [REDACTED]

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

Other related deaths This report is being sent to: Northern Care Limited

02/04/2024

2024-0179

Robert Fuller

South Yorkshire East

OBE Chief Executive, Doncaster Royal Infirmary

On 8 August 2022 I commenced an investigation into the death of Robert Fuller, age 71. The investigation concluded at the end of the inquest on the 21st March 2024. The conclusion of the inquest was that Mr Fuller died in Doncaster Royal Infirmary on the 22nd July 2022 as a result of natural causes. � 1a Cerebrovascular disease and ischaemic heart disease II����� Hypertension and type II diabetes mellitus

Mr Fuller was admitted to Doncaster Royal Infirmary on the 11th June 2022 with increased confusion. Investigations revealed that he had suffered a transient ischemic attack. He was medically fit for discharge by the 13th June 2022 but the discharge was delayed due to him needing social care involvement prior to discharge. Mr Fuller was transferred to Mallard Ward within the frailty unit on the 14th June 2022. This ward is a locked ward because between 50 and 75% of the patients suffer with dementia of varying degrees together with some experiencing challenging and unpredictable behaviour � On the 10th of July Mr Fuller was transferred out of his shared room due to a verbal disagreement with a fellow patient (Patient A). On the 3rd July 2022, Patient A kicked Mr Fuller�s feet whilst he was sleeping in a chair on the corridor. This caused no injuries. On the 1oth July 2022, Mr Fuller was walking down the corridor when Patient A punched him at the side of the head causing him to fall, hitting his head on the radiator before coming to rest on the floor. Investigations immediately after the incident revealed a new small traumatic bleed in the brain. Mr Fuller was transferred to a different ward. � Mr Fuller�s condition fluctuated over the next few days but then deteriorated further due to a number of factors including covid, severe longstanding cerebrovascular disease and delirium. The pathological evidence confirmed Mr Fuller had suffered a new large stroke in the days prior to his death on the 22nd of July 2022. The pathology evidence confirmed that the injuries Mr Fuller sustained in the assault and subsequent fall did not cause or contributed to his death. Therefore, a conclusion of natural causes was recorded .

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED]and DAC Beachcroft solicitors. � l am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 2nd April 2024

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

19/07/2024

2024-0394

Benjamin Harrison

Mid Kent & Medway

OXLEAS NHS FOUNATION TRUST, THE�GOVERNOR HMP ROCHESTER

On 16 May 2022 I commenced an investigation into the death of Benjamin Noah Frances�Harrison. The investigation concluded at the end of the inquest listed 3rd June 2024 with a� jury. The conclusion of the inquest was� Accident- Benjamin Harrison having inhaled fumes from a�[REDACTED] causing his death. �� Central issues which possibly contributed to the death: �� Insufficient healthcare cover at HMP Rochester. �� Omission of the OSG officer to inform the night orderly officer of Mr. Harrison�s appearance �after 21.30 on 9th May 2022. �� Central issues which are relevant to the death but did not cause or contribute to the death: �� Omission to arrange a GP review at HMP Elmley after the chronic pain multi-disciplinary team clinic was cancelled. �� Omission to follow up a referral to the specialist pain team at HMP Elmley. �� Omission to refer Mr. Harrison to the substance misuse team at HMP Elmley. �� Lack of communication regarding the handover of Mr. Harrison from HMP Elmley to HMP� Rochester and between healthcare staff and prison staff at both prisons. �� Inadequate number of prison officers on duty on the wing on the night shift at HMP Rochester Lack of first aid training for OSGs.� 1a [REDACTED] Toxicity

Benjamin Harrison was released from HMP Elmley in January 2021 and recalled on 19th March 2022. �� He had been prescribed a number of medications in the community for chronic pain which increased the risk of respiratory and central nervous system depression, namely�[REDACTED] and a [REDACTED]. Whilst at HMP Elmley consideration was given to reducing the medication but this had not�been addressed before he was transferred to HMP Rochester on 5th May 2022. Following his� arrival at HMP Rochester a GP recommended reduction of the opioid medication and the issue was tabled for discussion at a complex case review meeting on 18th May 2022 how best to� effect this. �� [REDACTED] are not recommended for use in prison because of the risks of� tampering and diverting. Mr. Harrison had a history of substance misuse and had previously�had his prescription stopped for this reason.� On the afternoon of 9th May 2022 Mr. Harrison was administered his medications including a�new ������ [REDACTED]. � His cell mate gave evidence that after he returned to his cell Mr. Harrison used a vape pen to�heat the [REDACTED] causing the chemicals within to be released which he then inhaled.� He did this on more than one occasion.� Around 8.35pm an OSG completed a roll check. She saw Mr Harrison lying on the bed and� was told by his cell mate that he was ok. She formed the impression that he was likely under� the influence of a substance. She did not alert the orderly planning to do welfare checks� instead.� She returned to the cell around 9.15 to check on Mr. Harrison. She saw him get off his bed� and described his as wobbly/hobbly which he attributed to having hit his leg. She stated he� was coherent.� The OSG stated that she returned on two or three further occasions and saw him sitting on the edge of his bed talking to his cell mate. �� Around 10pm she asked Mr. Harrison�s cell mate if Mr. Harrison was ok as he was lying on the� bed and she couldn�t see his face. She was told he was asleep and did not make any further� enquiry because she thought he would be better sleeping it off.� Neither she nor the orderly could remember if they discussed that Mr. Harrison was under the� influence around this time when the orderly came onto the landing.� At around 11.55pm Mr. Harrison�s cell mate raised the alarm stating he had realised that Mr.� Harrison had not moved for a while. He could not be roused and a code blue was called.� Cardiopulmonary resuscitation was commenced and continued until shortly after the arrival of� the ambulance when life was declared extinct.� The jury rejected the evidence of the OSG in relation to her observations of Mr. Harrison being alive and well after 9.30 based on the evidence of the cell mate and the pathological evidence� as to how long Mr. Harrison had likely been dead.

8. � I have sent a copy of my report to the Chief Coroner and to the following Interested Persons� Family of Mr. Harrison� I am also under a duty to send the Chief Coroner a copy of your response.� The Chief Coroner may publish either or both in a complete or redacted or summary form. He� may send a copy of this report to any person who he believes may find it useful or of interest.� You may make 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: Oxleas NHS Foundation Trust | HMP Rochester

10/07/2023

2023-0235

Harold Wilberforce

East Riding and Hull

Orchard 2000 Pharmacy General Pharmaceutical Council

On 10 February 2023, I commenced an investigation into the death of Harold Wilberforce, aged 87 years. The investigation concluded at the end of the inquest on 7 July 2023. The conclusion of the inquest was Accidental Death. � Box 3 of the Record of Inquest read: � Mr Wilberforce had an unwitnessed fall on 16 January 2023 at his home address, [REDACTED] . He suffered a left hip fracture, was taken to hospital and died of bronchopneumonia. � His medical cause of death was recorded as: � 1a Bronchopneumonia 1b Left hip intracapsular neck of femur fracture (operated) 1c Fall II�Chronic Obstructive Pulmonary Disease, Dementia, Cardio-renal Syndrome.

Mr Wilberforce had a fall at his home address on 16 January 2023. An employee from a pharmacy delivery centre located him and assisted him to a chair. He was complaining of a leg injury and resisted her efforts to call an ambulance. The emergency services were not called. A note was left by the pharmacy delivery agent to say that Mr Wilberforce had had a fall.� She left the premises.� Mr Wilberforce was then located, after having suffered a further fall, by his neighbour much later the same evening. � He had suffered a broken hip and was taken to hospital. In hospital, Mr Wilberforce contracted bronchopneumonia. He died on 28 January 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family of Harold Wilberforce. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make 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: Orchard 2000 Pharmacy and General Pharmaceutical Council

09/01/2025

2025-0013

Anthony Paine

Oxfordshire

Oxfordshire County Council Highways Department

INVESTIGATION AND INQUEST On 12th April 2023 I commenced an investigation into the death of Anthony John PAINE, a 75 year old male. The investigation concluded at the end of the inquest on 7 January 2025 and my conclusion as to the death was one of Road Traffic�Collision.

At approximately 22:45 hours on Friday 24th March 2023, a fatal road traffic collision occurred on the A361 North Bar Street, Banbury, Oxfordshire. A red Nissan Pixo collided with a pedestrian, Anthony Paine on the A361 North Bar Street, Banbury. Mr. Paine was crossing the carriageway on a pedestrian crossing from right to left as viewed by the driver of the Nissan. The pedestrian crossing was controlled by traffic signals.� Mr Paine did not wait to use the pedestrian controlled lights having considered the that the road was clear. He was struck by the vehicle and sadly died at the scene.

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

Oxfordshire County Council

01/03/2023

2023-0080

Annabel Findlay

Inner West London

PRIORY HOSPITAL, ROEHAMPTON

On 27 September 2021, I commenced an investigation into the death of Annabel Jean Findlay who died aged 56 years� old. The investigation concluded at the end of the inquest on 1 March 2023. The conclusion of the inquest was a short-form conclusion of suicide. The medical cause of death was determined to be fatal pressure to the neck.

Ms. Findlay had a history of psychiatric illness and a long history of depression, for which she was receiving support and treatment. She was an outpatient under the care of psychiatrists at the Priory Hospital, Roehampton from 7 February 2018 until 20 August 2021. She was noted as not always engaging with medical professionals and disclosed that she had been self-medicating. � On 20 August 2021, Ms. Findlay was admitted as an inpatient at the Priory Hospital, Roehampton, following a referral from her General Practitioner for �various complaints�. Ms. Findlay had been taking the anti-depressant venlafaxine but this had resulted in unintended urinary retention and prior to her admission, her intake was being reduced by her treating psychiatrists. On 20 August 2021, following her admission, she was started on a different anti-depressant, vortioxetine and attended to by staff and medical professionals. � On 27 August 2021, Ms. Findlay discharged herself from the Priory Hospital, Roehampton. This was despite the requests of her treating psychiatrist for her to remain so that her response to her change of medication could be monitored. � At the time of discharge, no significant risks were identified and Ms. Findlay was deemed to have capacity and was deemed fit for discharge. A discharge plan was put in place. � The discharge plan for Ms. Findlay included that she was to contact the hospital to make an outpatient appointment. She was also discharged with a week�s supply of medication. A discharge summary was sent to her GP.

1 March 2023 J. Taylor

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

Priory Hospital

01/05/2024

2024-0242

Laura Gawthorpe

West Yorkshire (Eastern)

Parking, Roads and Transport, Leeds City Council

On 7th October 2022 I commenced an investigation into the death of Laura Gawthorpe 07/07/1987. The investigation concluded at the end of the Inquest on 30/04/2024. The conclusion of the Inquest was that Mrs Gawthorpe�s death was a suicide.

Laura Gawthorpe was a voluntary patient at the Becklin Centre, Alma Street, Leeds. On 13th September 2022, she left the Becklin Centre on unescorted leave and made her way [REDACTED], where CCTV tracked her making her way to levels [REDACTED] of the car park, and thence back down [REDACTED] from where she deliberately fell to the ground below, dying instantly from unsurvivable injuries.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; [REDACTED] (Mrs Gawthorpe�s husband), Leeds and York Partnership 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.

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

17/02/2023

2023-0064

Twm Bryn

North West Wales

Interim Chief Executive of Betsi Cadwaladr University Health Board, Gill Harris

On the 12th October 2021, I commenced an investigation into the death of Mr Twm Bryn, aged 21. The investigation concluded at the end of the inquest on the 15th February 2023.

Mr Twm Bryn died on the 4th October 2021 in a shipping container located near his home address having suspended himself by the neck with a ligature. � Mr Twm Bryn had experienced mental health difficulties, including anxiety and low mood since the age of 17. Mr Bryn was referred to Gwynedd Mental Health services after a telephone consultation with his GP on the 26th July 2021. Due to the presence of low mood and anxiety, the referring Dr requested a routine assessment and possibly counselling. � Mr Bryn lived with family, had good friends and a job that he liked. The referral outlined low mood for a �few� years with a deterioration in the last �few� months which included feelings of panic, tiredness, poor sleep and appetite with no reported use of illicit substances or excessive alcohol consumption. The referral indicated that Twm Bryn described to the GP feelings �hitting him like a wall� when upset and angry, and at times, thoughts of wanting to harm himself and occasional suicidal thoughts. � An appointment with the Local Primary Mental Health Support Service (�LPMHSS�) was arranged and took place, via telephone assessment, on the 7th September 2021, 40 days after Mr Bryn was seen by the GP (not within the 28 day target set by the Mental Health Measure). The assessment indicated the presence of long-term low mood accompanied by anxiety, poor sleep and appetite. He was assessed as a mild risk of suicide, and no risk of harm to others with no legal/forensic risk. Mr Bryn was not at risk of abuse in his personal relationships nor at home and no safeguarding concerns were identified. � The primary care assessment was discussed at an Allocation meeting on the 13th September 2021 where a decision was made to offer counselling with the Local Primary Mental Health Support Service. There was a waiting list of several months for the said counselling and save for services to which he would need to self-refer, no interim contact, monitoring or support was discussed or offered to Mr Bryn. � Mr Bryn died before counselling was made available to him.

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

Wales prevention of future deaths reports (2019 onwards) | Suicide (from 2015)

Betsi Cadwaladr University Health Board

22/03/2023

2023-0100

Kenneth Adams

Dorset

International Academics of Emergency Dispatch, Suite B, 4th floor, Spectrum, Bond Street, Bristol BS13LG

On the 5th November 2021, an investigation was commenced into the death of Kenneth Michael Adams, born on the 2l5t August 1951. The investigation concluded at the end of the Inquest on the 9th March 2023. The Medical Cause of Death was: la Hypoxic brain damage lb Cardiac arrest le Profuse bleeding from a laceration of the scalp � 2 Treatment with clopidogrel for stenosing atherosclerosis of carotid arteries � � The conclusion of the Inquest recorded that Kenneth Michael Adams died as a consequence of an accident to which a failure to provide emergency medical assistance in a timely manner more than minimally contributed. A failure of the Medical Priority Despatch System to acknowledge and assess persistent bleeding from a scalp injury against a background of anti-platelet medication also possibly contributed to his death.

At approximately 3.30am on 19th October 2021, Kenneth Michael Adams, who was prescribed clopidogrel and who lived alone at 60 Vernons Court in Bridport, which is supported housing provided by a housing association, suffered an accidental fall from a standing height, which resulted in a laceration to his scalp. At 4.06 am Mr Adams contacted the ambulance service to explain that he had fallen, injured his scalp and that he could not stop the bleeding. Mr Adams� call was triaged using the Medical Priority Despatch System, which resulted in a disposition of 17-b-01: fall possible dangerous area. This translated to a category 3 ambulance response. The national target set by the Department of Health is to attend category 3 incidents within 120 minutes on at least 90% of occasions (so by 6.13 am), with an average response time of 60 minutes (by 5.13am). At the time of this call, Mr Adams appeared well with no additional symptoms. Mr Adams had also activated his careline, which is an element of the support provided by the housing association. At 7.53 an operator from the careline contacted Mr Adams to check on his welfare. Mr Adams reported that he was now feeling sick, that he was wobbly when stood up and that his bleeding was continuing. The careline operator contacted the ambulance service and advised of the new symptoms. A further triage was conducted, with the same disposition of fall, possibly dangerous area being reached, as the algorithm being used failed to account for the persistent nature of the bleeding being experienced and that Mr Adams was prescribed clopidogrel. At 10.25 Mr Adams again spoke to a careline operator. He was by now slurring his words and his speech was noticeably slow. It is likely he was experiencing symptoms associated with hypovolaemic shock. If Mr Adams had received treatment �by 10.25, he would have survived the injury he had sustained. The first ambulance resource arrived at Mr Adams� property at 11.56, by which time a neighbour had found Mr Adams when Mr Adams had called for his help. Mr Adams was conveyed to Dorset County Hospital, where despite treatment he died on 19th�October 2021.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� (1)�� Prince Evans Solicitors �(solicitors for� brother of Mr Kenneth Adams); (2)�� Browne Jacobson Solicitors (solicitors for South Western Ambulance Service NHS Foundation Trust); (3)�� Appello Limited � I� am also under a duty to send the Chief Coroner a copy � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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)

International Academics of Emergency Dispatch

24/08/2023

2023-0310

Christopher Locke

Swansea Neath Port Talbot

JD WETHERSPOONS PLC WETHERSPOON HOUSE CENTRAL PARK REEDS CRES WATFORD WD24 4QL

On the 11th August 2022 I commenced an investigation into the death of Christopher James Locke. The investigation concluded at the end of the inquest on the 24th of August 2023. � The medical cause of death is 1a) hypoxic ischaemic encephalopathy 1b) cardiac arrest 1c) cardiac arrhythmia in a man with a fatty heart who had sustained a blow to the head � The conclusion of the inquest as to how Mr Locke came to his death was a narrative conclusion and is as follows: The deceased died from hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac arrhythmia in a man with a fatty heart and sustained a blow to the head. The emergency services did not instruct the caller to initiate chest compressions when given sufficient information to give that instruction, and this more than minimally contributed to the deceased�s death

The deceased was Christopher James Locke and he was pronounced dead on the 29th October 2021 at Morriston Hospital, Swansea. The cause of death was hypoxic ischaemic encephalopathy, caused by a cardiac arrest, which itself was caused by a cardiac. � Christopher was admitted to Morriston Hospital via UHW Hospital Cardiff on the 23rd October 2021 having sustained a cardiac arrest at the Lord Cradoc public house, Port Talbot during the evening of the 21st of October 2021. The cause of the cardiac arrest was found to be a cardiac arrhythmia. The staff at the Lord Cradoc called 999 and followed the instructions provided by the Emergency Medical Dispatcher (EMD). The EMD did not instruct the staff to undertake CPR. Christopher�s circulation was restored 12 minutes after the arrival of the paramedics, who arrived 8 minutes after the commencement of the call. It was therefore estimated that Christopher had been without oxygen for at least 20 minutes. Christopher died from a brain injury caused by this lack of oxygen

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

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

13/11/2024

2024-0623

Andrew Howat

North Wales (East and Central)

Kingkabs, Wheatsheaf Garage, Parkgate Road, Cheater, CH1 6JS

On the 16th of October 2022 I commenced an investigation into the death of Andrew Howat�� (DOB 29.01.82 DOD 15.10.22). The investigation concluded at the end of the inquest on the 12th of November 2024. The cause of death was recorded as being due to 1(a) Multiple Injuries and� the conclusion of the inquest was that the death was due to a road traffic collision

On the 15th of December 2022, the deceased was collected by a Kingkabs taxi from a� Chester Hotel. He was intoxicated at the time and as a result of disruptive behaviour the� driver felt it unsafe to continue the journey and dropped him at a petrol station. Another� taxi was ordered from the same firm, and he was collected for his onward journey home. Again as a result of his disruptive behaviour the driver was not prepared to continue the� journey without full payment of the fare and stopped in a layby on the A483 dual� carriageway in an unlit area with no means by which a pedestrian could easily leave the� area (notwithstanding that there was a junction approximately 400 metres away which� would have been a safe place to discharge the passenger).�� When the deceased got out of the taxi, the drive left him in an unsafe location and no� contact was made with the police by the firm to advise them of the potential risk to both� the deceased and other traffic.

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

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

Kingkabs

19/07/2023

2023-0258

Sylvia Pollitt Coroner name: Alison Mutch Coroner Area: Manchester South Category: Other related deaths This report is being sent to: L&Q Group Housing

L&Q Group Housing

On 2nd December 2022 I commenced an investigation into the death of Sylvia Pollitt. The investigation concluded on the 16th June 2023 and the conclusion was one of Narrative: Died from hypothermia when her request for an engineer visit when she had concerns about her boiler did not happen and non-contact with her was not escalated. The medical cause of death was 1a) Gastro-intestinal haemorrhage; 1b) Acute Gastric Erosions; 1c) Hypothermia

Sylvia Pollitt was an elderly resident of a property owned by L&Q. She called them to highlight a concern with her boiler. The call was passed to Liberty who were subcontracted to provide gas services. They were unable to contact her and closed the call down, They should have escalated the situation. On 1st December 2022 Sylvia Pollitt was found in her home address 1 Seamons Walk. Post mortem examination found she had died from complications of hypothermia.

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

16/11/2023

2024-0096

Harry Colledge

Lancashire and Blackburn with Darwen

Lancashire County CouncilMr Colledge�s FamilyChief Coroner

On the 3rd January 2023 the Coroner�s Office was notified of the death of Harry College and an investigation commenced into his death. An inquest was opened and adjourned on the 17th January 2023 and a final inquest took place on the 12th and 13th October 2023. The conclusion of the inquest was that: � �Harry COLLEDGE died on the 2nd January 2023 at the Royal Preston Hospital as a result of injuries he sustained having been thrown from his bicycle. Mr COLLEDGE was an otherwise fit and healthy man who was a keen cyclist. On the 2nd of January 2023 he was cycling along Island Lane, Winmarleigh when his bicycle entered a crack defect in the carriageway, causing him to be thrown from his bicycle. This defect had been identified to the relevant Council in September 2022 and the subject of highway inspections on the 15th and 26th September 2022, involving six highways team operatives. Despite the Council�s notification of the defect and its approximate location, these inspections did not identify the defect which caused Mr COLLEDGE�s injuries and thus a dangerous hazard had remained on Island Lane from 9th September 2022 to 2nd January 2023.�

Circumstances of the death Mr Harry Colledge was a fit and active 84 year old man. On the 2nd January 2023 he was cycling his bicycle with a friend, a common activity for Mr Colledge. He was riding along Island Lane, Winmarleigh when his bicycle entered a crack defect in the carriageway causing him to be thrown from his bicycle and sustain injuries which caused his death. The crack defect in question had been seen by local residents and members of the local Parish Council on the 9th September 2022. They took photographs of the defect and others on the road, and reported them to the Highways department at the Lancashire County Council. The senior manager who received the photographs tasked others to inspect the road and repair the defects. Four Highways operatives attended the road in two vehicles on the 15th of September 2022. The road was driven in its entirety and no defects were noticed or repaired. A second, scheduled inspection took place by Highways inspectors on the 26th of September 2022. This also involved two operatives conducting a driven inspection and neither observed the crack defect which caused Mr Colledge�s collision. Consequently the crack was not repaired and remained hazardous in the roadway at the time of Mr Colledge�s incident and death.

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

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

10/11/2023

2023-0441

Christopher Allum

East Sussex

Langford Centre NHS England

On 19 May 2022 I commenced an investigation into the death of Christopher Richard ALLUM aged 36. The investigation concluded at the end of the inquest on 08 November 2023. The conclusion of the inquest was that: � Christopher Richard Allum died as a result of suicide.

Christopher Richard Allum had a history of escalating mental health issues from March 2022. � On 26 March 2022 he attended A&E [REDACTED]. He reattended hospital on 28 March 2022 after a further incident of deliberate self-harm [REDACTED]. He presented to hospital again on 29 March with suicidal ideation and a further incident of deliberate self- harm. � On 23 April 2022 whilst in a ward setting, Christopher [REDACTED] in an attempt to be suspended. Christopher was later discharged and on 9 May 2022 he disclosed to mental health professionals that he[REDACTED] . On 11 May 2022, he self-harmed again at his home address [REDACTED]. He was admitted to hospital and on 13 May 2022 he disclosed to a member of staff that he had [REDACTED]. These previous incidences were recorded in Christopher�s care notes. Christopher was admitted to the Langford Centre on 14 May 2022. His risk of suicide and self-harm was rated as high at the time of admission. The referral paperwork received by the Langford Centre made reference to the previous incidences of cutting and drinking of corrosive substances but did not mention ligatures. Christopher�s care notes were not accessed by staff at the Langford Centre until after his death. There was no record of Christopher arriving at the Langford Centre with a belt, nor any record of a belt being within his possession nor taken from him at any stage. � On the evening of 15 May 2022, Christopher was found unresponsive in his room � [REDACTED] Paramedics were called and CPR was attempted, however, it was not possible to revive Christopher and death was confirmed at 23:01.

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

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

13/03/2023

2023-0087

Gunapathyammah Ragnanathan

West London

Lean on Me care agency

On 22 July 2021 I commenced an investigation into the death of Gunapathyammah Ranganathan . The investigation concluded at the end of the inquest on 15 February 2023. The conclusion of the inquest was Medical cause of death � 1a Traumatic Intracerebral Haemorrhage and skull fracture 1b Fall � II Frailty, Type 2 Diabetes Mellitus, Hypertension, Rheumatoid Arthritis Mrs Ranganathan was elderly and frail and required the assistance of one carer to mobilise. On 11th July she was attended by a new, inexperienced carer who had insufficient training and shadowing to enable her to support Mrs Ranganathan safely during the morning care visit. While walking with her zimmer frame to the bathroom she was unattended and lost her balance, fell backwards and hit her head. She sustained a severe head injury that was unsurvivable and she died in St Mary�s Hospital on 14 July 2021. Had she been assisted in an appropriate way, it is probable that the fall could have been avoided. Conclusion Accidental Death

See above

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

Care Home Health related deaths

Lean on Me Care Agency

25/07/2023

2023-0279

Paul Keating

West Yorkshire (Eastern)

Leeds City Council Civil Litigation and Housing Section, [REDACTED], Principal Legal Officer Deputy Director, Fire Safety, Home Office, [REDACTED]

On 28/04/2023 I commenced an investigation into the death of Paul Keating, aged 59 (17/12/1963). The investigation concluded at the end of the Inquest on 20/07/2023. The conclusion of the Inquest was that Mr Keating�s death was accidental, caused by the combined effects of Carbon Monoxide toxicity and Ischaemic Heart Disease.

Paul Keating died on 15th April 2023 from the combined effects of carbon monoxide toxicity and pre-existing heart disease in a fire at the flat where he lived alone. The likely cause of the fire was the careless discarding of smoking materials in his bedroom. As he was entitled to, he had declined to allow contractors to install a sprinkler system in his flat when his local authority landlord was seeking to install such systems in all of their high rise properties following the Grenfell Tower disaster.

I have sent a copy of my report to the Chief Coroner and to the West Yorkshire Fire & Rescue Service Fire Investigation Team (an interested person 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.

Other related deaths This report is being sent to: Leed City Council and Home Office

19/07/2023

2023-0253

Carole McQuinn Coroner name: Catherine Cundy Coroner Area: North Yorkshire and York Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Leeds Teaching hospitals and York Hospital Legal trust

Leeds Teaching hospitals York Hospital Legal trust

On 16 May 2022 an investigation was commenced into the death of Carole MCQUINN aged 66. The investigation concluded at the end of the inquest on 11 July 2023. The conclusion of the inquest was that the deceased died as a consequence of a recognised complication of necessary surgery to treat pancreatic cancer, namely a pulmonary embolism which was likely to have developed as a result of post-operative infection, inflammation and immobility.

On the 21st of February 2022 the deceased underwent a distal pancreatectomy and splenectomy at St James�s University Hospital, Leeds to treat a malignant pseudo papillary tumour. She subsequently developed leaking of fluid from the remnant pancreas which is a recognised complication of this surgery and for which an abdominal drain was sited. She had a prolonged in-patient admission, during which she required periods of intravenous antibiotic therapy to treat abdominal collections, drainage of a pleural effusion and nutritional support via naso-gastric feeding and total parenteral nutrition. Her abdominal drain was removed on the 11th of April 2022. She was discharged home on the evening of the 20th of April 2022 without a discharge note or medication, which were not supplied until the following day. No follow up appointment was booked for the deceased. On the 21st of April 2022 the site of her previous abdominal drain was leaking pus. A swab was taken of the site and booked in to St James�s Hospital for testing on the 22nd of April 2022. The results of the swab were reported on the 26th of April 2022 but not reviewed by a member of the clinical team until the 3rd of May 2022 when oral antibiotics were commenced. On the evening of the 4th of May 2022 the deceased was found collapsed at home and was admitted to York Hospital by ambulance. She was treated for intra-abdominal sepsis and her observations stabilised, but she was found unresponsive in her hospital bed on the morning of the 7th of May 2022.

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

27/06/2023

2023-0214

Richard Littlewood

East Riding and Hull

Local Authority for East Riding of Yorkshire � Highways Department

On 2nd August 20222 I commenced an investigation into the death of Richard Stephen LITTLEWOOD, aged 40 years. The investigation concluded at the end of the inquest on 26th June 2023. The conclusion of the inquest was Road Traffic Incident. � Box 3 of the record of inquest read: � On 8th July 2022 Richard Stephen Littlewood was travelling on his motorcycle on the A1033. As he rounded a bend his motorcycle crossed the white line and he struck an oncoming vehicle. Mr Littlewood was conveyed to Hull Royal Infirmary with multiple traumatic injuries. He spent 3 weeks in intensive care but died on 29th July 2022, he was 40 years of age. � One of the findings of fact stated: The Forensic Collision Investigator feels, and I agree, that it was likely rider error, braking on the bend caused the motorcycle to become upright and travel in a straight direction. � Mr Littlewood�s medical cause of death was recorded as: COD: 1a����Bronchopneumonia 1b��� Multiple traumatic injuries 1c����Road traffic incident

Mr Littlewood was travelling on his motorcycle with a friend in convoy, he has braked when taking a bend in the road causing his motorcycle to travel in a straight line and into the path of an oncoming vehicle. He was conveyed to Hull Royal Infirmary with traumatic injuries. He died 3 weeks later 29th July 2022.

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

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

12/03/2024

2024-0133

Jason Brown

Sunderland

Lundbeck Limited National Pharmacy Association General Pharmaceutical Council Medicines and Healthcare Products Regulatory Agency

On 12th September 2022 I commenced an Investigation into the death of Mr Jason Brown, who was born on 28th November 1970 and who died at 3 Cheviot Lane, Sunderland on 6th September 2022 aged 51 years. The Investigation concluded at the end of an Inquest on 29th February 2024. The conclusion of the Inquest was �Suicide�. The medical cause of death was: Ia Cardiac Arrhythmia Ib Drug Overdose

Jason Brown died at his home address of 3 Cheviot Lane, Sunderland on 6th September 2022 having taken an overdose of his medication.

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

Suicide (from 2015) This report is being sent to: Lundbeck Limited | National Pharmacy Association | General Pharmaceutical Council | Medicines and Healthcare Products Regulatory Agency

18/08/2023

2023-0353

Devon Turner

Berkshire

MEDTRONIC ROYAL BERKSHIRE NHS FOUNDATION TRUST BERKSHIRE INTEGRATED CARE BOARD MEDICATION AND HEALTHCARE PRODUCTS REGULATORY AGENCY NHS ENGLAND

INVESTIGATION � On 23 November 2020, I commenced an investigation into the death of Devon Drew Turner aged 16 weeks. The investigation concluded at the end of the inquest on 16 August 2023. The conclusion of the inquest was natural causes. The medical cause of death was Sudden Unexpected Death in an Infant with Trisomy 9 Mosaicism (SUDI with Mosaic Trisomy 9)

1.� Devon Drew Turner was born on 17 January 2022 at Basingstoke and North Hampshire Hospital. He died on 10 May 2022 at Royal Berkshire Hospital of Sudden Unexpected Death in an Infant with Trisomy 9 Mosaicism. (SUDI with Mosiac Trisomy 9) 2.� Devon was born with a number of abnormalities due to a rare chromosomal disorder, Mosaic Trisomy 9 which had caused him serious health vulnerability, and particularly with his respiratory system, throughout his short life. He had been admitted to the Paediatric Intensive Care Unit twice. 3.� On 21 April 2022 he was discharged home to live with his parents and needed respiratory support on a CPAP machine throughout the night and for long periods during the day and monitoring on a SATS machine. Throughout Devon�s time at home he was visited by the community nurses every 2-3 days and the family were supported by the specialist nurses at UHS. 4.� On 30 April 2022 he was admitted to Basingstoke and North Hampshire Hospital with an increasing need for CPAP but was discharged the following day at 12.50pm as he remained stable. 5.� On 10 May 2022 Devon was given his 1am feed and the family settled down to sleep. At 4.30am Devon�s mother woke to find him unresponsive. An ambulance was called and he was taken to the Royal Berkshire Hospital but despite the best efforts of the medical teams he could not be revived and he died the same morning. Despite extensive post-mortem examination by a number of specialists it was not possible to come to any firm conclusion about what specifically caused his death, and the cause of death was given of SUDI with Trisomy 9 such that it was possible to conclude that it was a natural death and was linked directly to his diagnosis of trisomy 9. 6.� On examination of the CPAP machine that was maintaining his breathing, no faults were identified and it was confirmed that the only interventions by human hand were consistent with the parents� account, namely that he was given his feed at 1pm, the parents had gone to sleep and had woken again at 4.30am to find Devon unresponsive, the CPAP machine continuing to blow. The CPAP machine recorded at 4.30am when they disconnected him from it and turned it off as they called 999. 7.� By contrast the SATS machine, which was also examined and confirmed to be functioning, was set to alarm when Devon�s oxygen levels fell below 90%, but despite his oxygen being recorded as falling below this level, an alarm was not heard by the parents. There are some anomalies in the evidence relating to the SATs machine. 8.� Firstly the SATS machine technician provided evidence that the data revealed that the machine was not used until 3 May 2022. The evidence suggested that it was the same machine that had been used by the family consistently since 25 April 2022. 9.� Secondly the SATS machine technician provided evidence that the data showed that from 1.44am to 2.00am the SATS machine would have been sounding an alarm that could be silenced temporarily by pressing a button but that the alarm would restart after 60 seconds, sounding again. The alarm sound on this machine was set on maximum. A second alarm would have been sounding at 2.00am due to a loss of pulse.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � �� The family of Devon Turner �� UHS NHS Trust � I have also sent it to � �� Medtronic �� Royal Berkshire NHS Foundation Trust �� Berkshire Integrated Care Board �� Medication And Healthcare Products Regulatory Agency �� 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.

Child Death (from 2015) This report is being sent to: Medtronic | Royal Berkshire NHS Foundation Trust | Berkshire Integrated Care Board | Medication and Healthcare Products Regulatory Agency� | NHS England

08/08/2024

2024-0460

Sean Davies

�Mid Kent and Medway

MINISTRY OF JUSTICE THE GOVERNOR HMP� SWALESIDE

On 6 March 2023 I commenced an investigation into the death of Sean Martin DAVIES. The investigation concluded at the end of the inquest . A jury found that:� Sean Davies died on 25th February 2023, between the hours of 03:00 and 07:15am, by� means of suspension, [REDACTED], in cell FS1-02 at HMP�Swaleside. He had an indeterminate sentence of imprisonment for public protection with a� tariff of 5 years imposed in November 2012. This lead to the progression from his status as�a B category prisoner to a C category prisoner and its revocation on the 1st October 2022,� followed by an unsuccessful appeal of that decision.� with a narrative conclusion:� Suicide �� Factors relevant to the death, but which cannot be concluded to have caused or contributed to the death include, a lack of communication and handovers between staff and insufficiently� completed welfare checks.� 1a Suspension 1b 1c II

Sean Davies, aged 30 at the time of his death, was remanded into custody in November 2011 for an offence of violence. In November 2012 he was sentenced to an indeterminate sentence for public protection (IPP), the minimum term being seven years later reduced to five years on appeal. He became eligible for parole in November 2017.� In 2021 Mr. Davies transferred to HMP Swaleside in order to join the psychologically informed planned environment (PIPE) unit where he was able to fully engage with a programme which� improved his chances of parole. In April 2023 he was assessed as suitable for a category C� prison but this was revoked in October 2023 following an incident in August when unprescribed medication was found in his cell.� Following this Mr. Davies expressed feelings of hopelessness at clinical sessions but� continued to engage and underwent a psychological assessment on 7th February 2023 which� was reported to have gone well. A parole hearing had not been scheduled.� On 10th February 2023 Mr. Davies was informed of the outcome of the justice committee�s� review of IPP sentences in that their recommendation for a resentencing exercise had been� rejected by the government� Thereafter he declined to participate in a further psychological assessment and suspended�himself in the early hours of 25th February 2023. There was CCTV evidence of him�[REDACTED]. The�[REDACTED] was visible to anyone patrolling the landing and was seen by an�operational support group officer who pointed it out to another but neither reported it.� Mr. Davies left a note stating that he had taken his own life because of the IPP sentence. He� expressed frustration at the slow progress of his sentence, re-categorisation and concerns� about how the parole board would view this and his past behaviour. He saw no chance of� being released. He went on to say that he hoped that his death would contribute for them to� change the laws of the IPP sentence.

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

Suicide (from 2015)

Ministry of Justice | HMP Swaleside

23/05/2023

2023-0170

Daniel Lyle

Inner West London

MPS [REDACTED] College of Policing [REDACTED]

On the 21st March, 22nd March and 23rd March 2023 evidence was heard touching the death of Daniel LYLE. He died on 20th March 2020 aged 46 years. � � Medical Cause of Death � I (a) Multiple Injuries � How, when, where Daniel LYLE came by his death: � At about 0820 on 20th March 2020 Daniel Lyle who suffered from paranoid psychosis had a psychotic episode in the garden area outside Morgan House, Tachbrook Street, London SWI. During the course of this episode he climbed approximately 30 feet up into a tree. Police officers tried to engage him in efforts to encourage him to come down safely from the tree, but he did not come down. During bis time in the tree he displayed paranoid and delusional beliefs. Whilst moving within the tree Daniel fell striking his head on the bard surface beneath the tree causing serious head and chest injuries. Despite effo1ts by police, fire brigade, ambulance and helicopter medical personnel to resuscitate him, Daniel died from� bis injuries� in the garden area outside Morgan� House, Tachbrook Street London. � Conclusion of the Coroner as to the death: Accident

: Extensive evidence was heard by the court in the form of written and oral evidence, and I was able to view the body worn video evidence of police officers who attended a call to police about Daniel�s behaviour that day. Of particular significance for the purpose of this report are the following matters: (1) Daniel suffered from paranoid psych~is and had done for many years. (2) Part of the, features of his psychosis were delusional beliefs. (3) On 20th March 2020 Daniel climbed high into a tree -over 25-30 feet above the ground whilst expressing delusional and psychotic beliefs that dead people were in the est.ate refuse bins. (4) Police officers attended and tried to encourage Daniel to come down from the tree for his safety. (5) He was approached and spoken to by more than one police officer until one officer PC [REDACTED] took over communication. (6) Other officers remained present but tried to keep a distance away and did not try to interfere with the one officer communicating with Daniel. (7) PC [REDACTED] the officer communicating with Daniel informed the court that he had received some training from the Metropolitan Police service in relation to dealing with those with mental health issues, and had received other training in different forces. He told me that he had pieced together information on how to deal with someone displaying mental health issues as a ��patchwork� over I 5 years. He told me that training on the presentation of symptoms and strategies to deal with those in mental health crisis would be something he would value. He said that whilst he did have some training and there was overlap in officer safety training, he would value individual training specifically on symptoms, presentation and strategies to de-escalate situations involving those displaying mental health difficulties such as psychotic and other distressed behaviour. (8) Daniel underwent an acute psychotic episode beginning before he entered the tree and whilst he was in the tree. Whilst moving within the tree Daniel fell sustaining fatal injuries. (9) Inspector [REDACTED] is the Central Mental Health and Adult Safeguarding team lead which sits within the Continuous Policing Improvement Command. [REDACTED] told me of initiatives and training developments addressing mental health within policing. [REDACTED] accepted that bespoke refresher training for frontline officers in helping to deal with those suffering mental health episodes was in the process of being developed by the MPS. [REDACTED] referred me to initiatives by the MPS Western Area Mental Health Team which had an element of training about the signs of mental ill-health and learning disorders, and general communication in a mental health crisis, and also referred to a one day course rolled out in 2018-19 for officers on mental health issues.

I have sent a copy of my report to the Chief Coroner and to the following lnterested Persons: The Family of Daniel Lyle [REDACTED] [REDACTED] (MPS) [REDACTED] IOPC � [REDACTED] LAS � [REDACTED] l am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make 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: Metropolitan Police Service and College of Policing

16/07/2024

2024-0376

Glenn Jacques and Ben Whiteman and Callum Clark

Durham & Darlington

Managing Director Northern Railway� 5th Floor� Northern House� 9 Rougier Street� York� YO1 6HZ

INVESTIGATION I have commenced investigations into the deaths of the following persons: Name: Glenn Jacques Collision and death: 14-Feb-24 Investigation� commencement: 15-Feb-24 Name: Ben Robert Whiteman Collision and death: 03-Jun-24 Investigation� commencement: 05-Jun-24 Name: Callum CLARK Collision and death: 05-Jul-24 Investigation� commencement: 08-Jul-24 The investigations have not yet concluded and the inquests have not yet been heard.

Each of the deceased persons died after being struck by a train travelling through� [REDACTED] railway station, County Durham; in each case, the person is reported to have put himself into the path of the train by deliberate, intentional action.

I have sent a copy of my report to the Chief Coroner and to Interested Persons to these investigations.�� I am also under a duty to send 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 whom 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.

Railway related deaths | Suicide (from 2015) � This report is being sent to: Northern Rail

05/12/2024

2024-0670

William Lardner

Dorset

Managing Director of Bournemouth International Airport Ltd Chief Executive of BCP Council

INVESTIGATION On the 5th July 2023 I commenced an investigation into the death of William Albert Nairn Lardner, aged 16 years. The investigation has not yet concluded, and the Inquest has not yet been heard.

On the evening of the 30th June 2023, William, known as Billy, had been working at one of the concessions at Bournemouth Airport. He finished work at approximately 9.30pm and walked from the airport main building, down Hurn Court Lane, the road upon which the airport is situated, towards the traffic lights on Parley Lane, Christchurch the main road outside the airport. Billy�s brother had arranged to collect Billy from work that evening. At approximately 9.34pm Billy was crossing Parley Lane at the traffic lights, at the junction with Hurn Court Lane, towards his brother�s car which had stopped at the lights when he was struck by a vehicle which had gone through a red light at speed. He sustained significant, traumatic injuries which led to his death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, namely Billy�s family and [REDACTED], and to the Local Child Safeguarding Board. I have also sent it to Dorset Police Road Casualty Reduction Officer, Regional and City Airports and the Highways Agency 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

Bournemouth International Airport Ltd | BCP Council

17/07/2023

2023-0245

Ross Ballatine, Carl McGrath, Alan Minard

North Wales East and Central

Maritime & Coastguard Agency, Spring Place, 105 Commercial Road, Southampton SO15 1EG

On 14 July 2023, sitting with a jury, I heard simultaneously the inquests into the deaths of three men (Ross Stephen Ballatine, Carl Stephen McGrath, Alan Wallace Minard), each of whom died from immersion/drowning after the fishing vessel on which they were working (Nicola Faith) capsized off the coast of North Wales on 27 January 2021. � In each case the jury returned a narrative conclusion in the same terms: �[The Deceased] died from immersion/drowning after the capsize of the fishing vessel which he was working on. The boat capsized due to the combination of the modifications of the vessel, the weight and distribution of the catch and equipment and its effect on the stability of the vessel�.

The vessel set sail on the morning of 27 January 2021 with its skipper and two other fishermen (the three deceased) on board. Their intention was to collect whelks for sale. The vessel capsized at around 18:00. The bodies of the three men were washed ashore at various points around the coast of North West England around 7 weeks later. � The vessel had been given a safety certificate following an inspection by the Maritime and Coastguard Agency in September 2017. Thereafter the vessel was modified in a number of ways, to improve functionality. The changes adversely affected the stability of the vessel. The vessel was inspected again twice by the same inspector from the Agency, in May 2019 and December 2020, following incidents which had been brought to the Agency�s attention by the Holyhead Coastguard. The inspector did not consider that the changes he witnessed warranted a formal stability assessment. He placed great weight upon his impression of the skipper�s competence and intentions concerning operational procedures. � It is likely that the vessel could have operated safely (in relatively calm waters, such as existed on the day of its capsize) with a load of up to 1 Tonne; but its actual load (which had not been distributed appropriately) was calculated to be closer to 4.6 Tonnes.

I have sent a copy of my report to the Family of the Deceased, the MAIB 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.

Other related deaths This report is being sent to: Maritime & Coastguard Agency

18/05/2023

2023-0164

Akash Bhudia

East London

Medica Reporting Services Ltd, Sixth Floor, One Priory Square, Hastings, East Sussex TN34 1EA

On the 30 May 2022, I commenced an investigation into the death of Akash Dinesh Bhudia, age 28 years. The investigation concluded at the end of the inquest on 16 May 2023. The conclusion was that Mr Bhudia died as a result of natural causes. The inquest however heard evidence in relation to non-causal concerns in relation to the reporting of chest radiographs.

Akash Bhudia suffered from a persistent cough from December 2021. On the 17 January 2022 he attended A&E where he underwent blood tests, chest Xray and medical reviews. The impression at this time was that he was suffering from community acquired pneumonia. He received a dose of intravenous antibiotics and intravenous fluids and was discharged from hospital with a course of oral antibiotics. Akash attended for a follow-up chest Xray on the 28 February 2022. This Xray showed progression in his left lung consolidation and showed a new consolidation in his right lung. The inquest heard that the primary diagnosis based on this Xray should have been tuberculosis. On the 4 March 2022, an emergency ambulance was called when Akash was found to be coughing and vomiting blood. Paramedics attended and provided emergency assistance. They could not however resuscitate Akash and his life was pronounced extinct by a paramedic. A post-mortem examination revealed a pulmonary abscess which was most likely to have been caused by tuberculosis. There is no evidence that any acts or omissions in the care provided to him, contributed to his death. The chest radiograph was not sent for analysis until 8 March 2022. The lack of an alert did not therefore contribute to Akash�s death.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons to the Inquest. I have also sent it to the local Director of Public Health, to the CQC and to the Royal College of Radiologists 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.

Other related deaths This report is being sent to: Medica Reporting Service

22/12/2022

2022-0411

Allah Ismail

Manchester City

Medical Director Healthcare Quality Improvement Partnership Ltd (HQIP) 27A Harley Place 45 Moorfields London EC2Y 9AE President of the British Thoracic Society 17 Doughty Street, London WC1N 2PL � Copied for interest to: � Family members of the deceased MFT NHS Trust

On the 30th July 2019 I commenced an investigation into the death of. The investigation concluded on the 15th December 2022. The Narrative Conclusion of the inquest was: The deceased died as a consequence of serious traumatic injuries she sustained in an accidental fall in Pakistan at about 02:30 hours on the 9 July 2019 which were not all initially diagnosed in combination with other serious comorbid conditions. She was not correctly assessed as being unfit to fly and during her flight back to United Kingdom on 12 July 2019 her condition significantly deteriorated. On arrival she was admitted to hospital in Manchester. Despite ongoing medical management her condition suddenly deteriorated on 25 July, and she died following day. She probably would not have survived even if aspects of her treatment had been different.

CIRCUMSTANCES OF DEATH 1.���� The deceased suffered from suffered from several serious chronic comorbid conditions. At about 02.30 hours on 9 July 2019 while staying in a property in Lahore, Pakistan when mobilising to go to the toilet she fell from a high bed onto a hard tiled floor and landed heavily. She was taken to the National hospital in Lahore where she was assessed as only having suffered a fractured clavicle. She was not diagnosed with also suffering from several fractured ribs which amounted to flail chest as well as a subdural haematoma. She was discharged from hospital on 10 July 2019 with a recording oxygen saturation level of 88% which should have precluded her from flying without supplemental oxygen being provided. She flew back to Manchester in the United Kingdom on 12 July 2019, but during the flight she suffered from serious cardiac and respiratory distress. On landing she was transferred to an ambulance and immediately taken to Wythenshawe Hospital in Manchester. 2.���� Shortly after admission she was diagnosed suffering from flail chest and a subdural haemorrhage in addition to a chest infection. She was treated with antibiotics and her usual heart medication was omitted. Her condition steadily improved and on 15 July 2019 she was referred to Huddersfield hospital in Yorkshire in order for her to be transferred for continuing rehabilitation and medical management. A bed was not initially available and on 19 July 2019 she was unable to be moved because her potassium levels high and her kidney function had deteriorated. On 20 July 2019 her condition had deteriorated, and she had developed the degree of fluid overload and was recommenced on a diuretic medication. 3.���� By 22 July 2019 she was noted to have had fluctuating drowsiness and an element of delirium and having little no oral intake. The administration of oxygen during her admission was appropriate, but on occasions not correctly documented. On the afternoon of 25 July 2019, she suffered a serious deterioration when, despite appropriate medical management and treatment, her condition deteriorated, and she died on 26 July 2019. Different medical treatment would have more than minimally increased the chances of survival, although, on the balance of probabilities, it would not have altered the eventual outcome. 4.���� The expert respiratory medicine witnesses in the case agreed that it was best practice for target oxygen saturations to be documented and for oxygen to be titrated to achieve these levels but in their experience, this is often poorly done on non- specialist wards and what happened Wythenshawe hospital was not uncommon. It was recognised that was certainly best practice, but the local MFT Trust guidelines are to prescribe oxygen. There was a national problem with oxygen prescribing which had been recognised by audits undertaken by the BTS. 5.���� There are no NICE guidelines, but the BTS guidance are clear. An audit that took place in 2015 indicated that Wythenshawe hospital was actually doing better than the rest of the country in complying with the guidance. There was a difference between a direction for oxygen being written in the clinical records as opposed to being recorded on a drug chart. In practical terms it was simply implementing the guidelines at the coalface which was the problem. It was not clear whether a re-audit being undertaken but there was a necessity for wider education of all physicians in the prescribing of oxygen within MFT NHS trust and more widely in the country. 6. Following the last BTS audit MFT took steps to address any patient safety issues that come from not prescribing oxygen and that was through the introduction of oxygen variance forms and there is ongoing programme of education for all doctors as they begin work at MFT. There still appears to be national inconsistency in addition to the use of both paper and electronic records with the added complication of a move towards using electronic records only. Patients are at risk of harm, serious harm, or death as a consequence of over oxygenation or under oxygenation. There was no evidence in the medical literature for the use of Bi level Ventilation for a patient with flail chest. Important Explanatory Notes: The BTS is a registered charity and not a governing body. The aim of the BTS audits are to support members to identify and improve standards of care for people with respiratory disease. The request for the BTS to undertake a further review and audit would be costly for this charity to conduct on a national scale. The BTS may be planning to update their 2017 guideline for oxygen use in adults in healthcare and emergency settings. The Healthcare Quality Improvement Partnership (HQIP), is the arm�s length, centrally funded, government body responsible for several national healthcare quality improvement programmes. From a funding, logistics and resources perspective, HQIP is likely to be better placed to consider the feasibility of a national audit programme. Therefore, and again pragmatically, it may be more appropriate for any national audit to take place following the introduction of the updated guideline, with appropriate funding in place, potentially from HQIP. It would be important for there to be co-ordination between the HQIP and the BTS. The BTS provides open access to its� audit tools. This allows hospital trusts to conduct recurrent audits for assurance against the agreed standards of care and also compare their data with the national picture as it appeared at the time of the previous audit period. The last BTS National Emergency Oxygen Audit was run in 2015. Consequently, there is an opportunity for HQIP to encourage Trusts to use the BTS audit tools to evaluate its data and performance now, pending a future national audit.

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

Child Death (from 2015) | Other related deaths

Healthcare Quality Improvement Partnership Ltd | British Thoracic Society

12/04/2024

2024-0214

Sabina Wood

Blackpool and Fylde

Medical Director, Blackpool Teaching Hospital NHS Foundation Trust Minister of State, Department of Health

The death of Sabina Wood on 27th January 2023 was reported to Blackpool Coroner�s Court and an investigation opened on 7th February 2023 which was concluded by way of an inquest held on 11th and 12th April 2024. � I determined that the medical cause of Sabina�s death was: � 1(a) Acute harmorrhagic pancreatitis 1(b) Chloelithiasis � The conclusion of the Coroner was that this death was a Natural Death.

I returned the following in box 3 of the Record of Inquest recorded: � Sabina Wood was admitted to the Blackpool Victoria Hospital on 11th January 2023 following complaining of right upper quadrant pain which she had been experiencing intermittently for a few months.�� A CT scan revealed the presence of gallstones and the possibility of stones in the bile duct. A MRCP scan was performed� on� 12th�� January� 2023� which� showed� bile� duct� stones �alongside evidence of inflammation of the gallbladder. An ERCP was performed on 23rd January 2023 which did not find gallstones in the bile duct. Sabina discharged herself from the Blackpool Victoria Hospital at 19.40 on 23rd January 2023 against medical advice. She had the capacity to self discharge herself from the hospital. Sabrina contacted North Shore GP Practice on 24th January 2023 complaining of pain in the region where the ERCP was performed and was prescribed oral morphine by the pharmacist following a telephone consultation taking place. Sabrina did indicate any symptoms other than pain and did not tell the pharmacist that she had left the hospital against medical advice. On 25th January 2023 Sabrina contacted the GP Practice and had a telephone consultation with [REDACTED]. During this consultation she did not describe any new symptoms and said that the morphine prescribed the day before was helping. On 27th January 2023, Sabina�s partner found her unresponsive in bed. Paramedics attended and confirmed her death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � The family of Sabina Wood � [REDACTED], GP Partner at North Shore Surgery � [REDACTED], Pharmacist at North Shore Surgery � A copy of the report will be circulated to the Medical Director of the Royal Preston Hospital and North West Regional Hospitals � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Blackpool Teaching Hospital NHS Foundation Trust | Department of Health and Social Care

01/12/2023

2023-0494

Samantha Shillito

West Yorkshire (Eastern)

Mid Yorkshire Teaching NHS Trust Royal College of Radiologists

On 11th March 2022 I commenced an investigation into the death of Ms Samantha Jade Shillito, aged 38. The investigation concluded at the end of the Inquest on 30 November 2023. A narrative conclusion was reached which recorded Ms Shillito�s medical history of alcoholic liver disease and depression. During a hospital admission in February 2022, she underwent an ascitic tap procedure that inadvertently perforated an artery, causing intra-abdominal bleeding that resulted in her death two days later. Within hours of the procedure, she was prescribed oramorph and other pain-relieving medications. The deterioration in her condition did not trigger a medical review and hence an opportunity was lost on the weekend of 25/26 February to initiate treatment to ameliorate this deterioration. She died on Sunday 27 February 2022 in Pinderfields Hospital, Wakefield. The medical cause of her death was attributed to (1a) intra-abdominal bleeding due to (1b) ultrasound guided ascitic tap and (2) cirrhosis, alcohol related liver disease.

Ms Shillito was significantly unwell when admitted to hospital on 16/1/22. The inquest heard evidence that her mortality risk was around 40%. She provided verbal consent to the ascitic tap procedure but was not told there was a rare possibility of death if a surrounding structure were to be perforated. It appeared the procedure had been accomplished uneventfully on Friday 25/2/22, but within hours she complained of pain around the site of the procedure. On the Friday evening and during Saturday (25/26 February) her condition deteriorated, yet she was not reviewed or examined, nor were any other investigations initiated which may have halted this decline. On Sunday 27 February she was found in an unresponsive condition and died that day. Her family had not been forewarned of the seriousness of her illness, nor that her life was in danger and consequently went home some hours before she died.

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

Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Mid Yorkshire Hospitals NHS Trust | Royal College of Radiologists

28/02/2023

2023-0073

Stephen Chapple and Jennifer Chapple

Somerset

Military of Defence [REDACTED] Secretary of State for Defence (Mr Ben Wallace) [REDACTED]

INVESTIGATION � On 22nd November 2021 my predecessor, Mr Tony Williams, commenced an investigation into the joint deaths of husband and wife, Stephen Roy Chapple and Jennifer Chapple. Inquests were opened and adjourned on the 9th December 2021. Upon Mr Williams� retirement, I took over conduct of the above cases on 01 April 2022 The investigation was suspended under Schedule 1 of the Coroners and Justice Act 2009 on the basis that an individual was charged with their murder.

Stephen and Jennifer Chapple lived on a residential housing development in Norton Fitzwarren. They became involved in a parking dispute with their neighbour, [REDACTED]. It would appear that [REDACTED] took umbrage at Jennifer, in particular, parking her vehicle in a particular location and manner within the development. She was perfectly legally entitled to park how and where she did; simply didn�t like it and took petty action of moving his bins to block spaces and/or parking his own vehicle in an inconsiderate manner to cause a nuisance. There were some instances of police involvement, but this was largely either deemed to be a civil matter or verbal harassment [REDACTED] by who embarked on a course of conduct designed to intimidate or frighten Mr, but more particularly Mrs Chapple. On the 21 st November 2021 at 09:45am [REDACTED] telephoned Avon and Somerset Constabulary and informed the call-taker that he had stabbed his neighbours, Mr and Mrs Chapple. They suffered significant wounds and were sadly pronounced deceased at the scene. The IOPC Report concluded that the Police acted appropriately to the incidents reported at the time and there was no indication from the previous conduct that physical violence and/or a double homicide offence was even a remotely foreseeable possibility. [REDACTED] was charged with the double murder and after a trial was sentenced at Bristol Crown Court on the 21 st June 2022 to a fixed minimum custodial term of 38 years.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to the Chief of Avon and Somerset Constabulary 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

Other related deaths

Ministry of Defence

26/10/2023

2023-0411

Jacqueline Carrey

Milton Keynes

Milton Keynes University Hospital Chief Executive

On 01 June 2023 I commenced an investigation into the death of Jacqueline Anne CARREY aged 56. The investigation concluded at the end of the inquest on 18 October 2023. The conclusion of the inquest was: � Drug related

The deceased was admitted to Milton Keynes University Hospital on the 11th May 2023 due to extreme pain from pancreatitis. She was discharged from hospital on the 16th May 2023 with an excess of�[REDACTED] medication despite warnings recorded that her medication should be restricted to seven days supply. She was found deceased at home Milton Keynes on the 25th May 2023 and the cause of death was [REDACTED] toxicity.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � I have also sent it to [REDACTED] (sister of Mrs. CARREY), Chief Executive of Milton Keynes University Hospital and 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.

Alcohol, drugs medication related deaths, Care Home Health related deaths This report is being sent to: Milton Keynes University Hospital

19/01/2023

2023-0048

Michael Allen

Milton Keynes

Milton Keynes University Hospital Litigation

On 03 November 2021 I commenced an investigation into the death of Michael ALLEN aged 56. The investigation concluded at the end of the inquest on 02 November 2022. The conclusion of the inquest was that: � Mr Michael Allen died on the 11th April 2021 at the Milton Keynes University Hospital. He was admitted on the 3rd April 2021 with gallstone pancreatitis. Subsequent to ERCP removal of the obstructing gallstone there were missed opportunities on the 9th April 2021 to recognise that he was developing sepsis and also then to manage it effectively.

Mr Michael Allen was an otherwise healthy man who developed gallstone pancreatitis and was admitted to Milton Keynes University Hospital on the 3rd April 2021. He died on the 11th April 2021 from 1a Acute pancreatitis and liver necrosis resulting from 1b Gallstone disease (ERCP 8th April 2021). Had he been effectively monitored and subject to senior surgical supervision during the 9th April 2021 it is more likely than not that he would have survived.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] [REDACTED] I have also sent it to Milton Keynes University Hospital Litigation 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

Milton Keynes University Hospital Litigation

18/12/2023

2023-0531

Vivienne Greener

North Wales East and Central

Minister for Health and Social Services Betsi Cadwaladr University Health Board (BCUHB)

On the 26.3.18 an investigation was commenced into the death of Vivienne Greener (DOB 24.8.53) who died at Glan Clwyd Hospital on the 20.3.2018. A narrative conclusion was recorded in the following terms: � 1. Ruthin Coroner�s Court 2. Inquest of Vivienne Greener 3. Conclusion � Box 4 of The Record of Inquest 18.12.23. 4. On the 19 March 2018, Mrs Vivienne Greener was taken by ambulance to the Glan Clwyd Hospital in response to vomiting blood at her home. She arrived at 00:21 hours. 5. Despite ambulance technicians seeking to have her admitted into the emergency department, they were told by hospital staff that there were no beds available. The emergency department was overrun, with insufficient numbers of medical staff. Corridors were full of patients as were the waiting areas in addition to up to 14 ambulances waiting to offload. 6. There were around 83 patients. The Health Board Clinical Site Manager was never alerted.There was no effective triage system whilst Mrs Greener was waiting outside the hospital. She had been vomiting blood. At 00:38 hours, her National Early Warning Score (NEWS) was 6 and at 01:11 hours, it worsened to 12 and she needed immediate attention. The Health Board failed to escalate her situation to senior staff and failed to go to the ambulance to examine her. The Health Board failed to admit her at 00:38 hours and give her clinical attention. 7. She was admitted into the emergency department at the further request of WAST at 01:20 where she continued to vomit blood and pass blood rectally. There was an unacceptable delay in the Health Board providing blood products to her because there were insufficiently trained staff available to access the blood safe, located in another part of the hospital, together with a doctor who preferred to wait for crossmatched blood, as opposed to emergency O negative blood. 8. The nurse in the resuscitation unit escalated the matter and Mrs Greener was then attended by the hospital medical registrar. There were insufficient suitably available doctors to help the registrar with resuscitating Mrs Greener. 9. Mrs Greener ought to have had emergency blood products at the earliest available opportunity when she entered the emergency department, and the delay in giving blood products was a missed opportunity to render care. 10. Junior doctors failed to escalate Mrs Greener�s serious condition to their on-call Consultants who would have been able to more quickly appreciate that she was on the verge of dying. 11. The Health Board failed to provide or resource an out of office hours endoscopy procedure. It also failed to follow the Massive Haemorrhage Pathway. Given that this was catastrophic bleeding, the Health Board should have summoned the Medical Emergency Team which ought to have brought together the medical registrar, surgical registrar, surgical junior doctor, anaesthetist junior doctor and intensive care unit nurse practitioner or a mixture of them, but failed to do so. These were significant missed opportunities to provide care to a patient who was suddenly dying, aware of it and frightened. Her treatment in the resuscitation unit was an acceptable venue for it and no less than she would have received in the Intensive Treatment Unit. �12. At the time, the source of the bleeding could not be identified. Had resuscitation occurred sooner when the opportunity presented, it could have been done more aggressively up to 01:30. This would have given her more chance of remaining alive for longer in the hope that an upper gastrointestinal surgeon would have come into the hospital during business hours and been able to operate on her. 13. Mrs Greener had been taking prescribed Naproxen, a non-steroidal anti- inflammatory, which stripped the lining of her stomach. Just as fast as the medical registrar was putting blood products into her, they were coming out. As a result, Mrs Greener never achieved haemodynamic stability, and any surgical intervention would have carried a mortality risk of up to 80% as she would not have been able to withstand anaesthetic or sedation. 14. An endoscopy would only have seen redness and not the source of the bleed. The only alternative would have been for a gastrectomy, the removal of the stomach. It is a very rare operation with a very high mortality risk. 15. I record the admitted failings of the Health Board and find the Health Board: 16. Failed to transfer the patient to the emergency department as Mrs Greener was on the ambulance for one hour; 17. Failed to provide documented evidence of triage with a member of emergency department staff attending the patient on the ambulance; 18. Failed to recognise a deteriorating patient; 19. Failed to trigger the massive haemorrhage pathway following the first set of observations in the emergency department; 20. Failed to recognise the early instigation and relevance of the major haemorrhage pathway; 21. Failed to document clinical review within medical records; 22. Failed to escalate the situation earlier, internally to on call consultants; 23. Failed to obtain blood products urgently. 24. Even given the ideal standard of care, Mrs Greener would not have survived the catastrophic bleeding. 25. Mrs Greener died due 1a multi organ failure due to 1b massive upper gastrointestinal haemorrhage due to 1c therapeutic use of Naproxen which led to her death at Glan Clwyd Hospital on 20 March 2018.

As per the above narrative conclusion.

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

Emergency services related deaths (2019 onwards) | Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care | Betsi Cadwaladr University Health Board

22/02/2024

2024-0107

Joseph Cattle

South Wales Central

Minister for Health and Social Services, Welsh Government

On 22 July 2022 an investigation commenced into the death of Joseph Leonard Scott Cattle. The investigation concluded at the end of the inquest 24/01/2024. The conclusion of the inquest was: � Alcohol related.

Mr Cattle contacted WAST at 0044 who categorised the call as requiring an Amber 1 response. There were 2 further calls between Mr Cattle and WAST at 0117 and 0325. Paramedics did not attended until approximately 0720 by which time Mr Cattle was deceased.

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

Alcohol, drug and medication related deaths | Wales prevention of future deaths reports (2019 onwards) This report is being sent to: Minister for Health and Social Services, Welsh Government

28/09/2023

2023-0363

Scott Donoghue

East Riding and Hull

Minister for the Department of Health � Rt Hon Steve Barclay MP

On 27th May 2022 I commenced an investigation into the death of Scott James DONOGHUE, aged 33 years. The investigation concluded at the end of the inquest on 28th September 2023. The conclusion of the inquest was Suicide. � Box 3 of the record of inquest read: Scott James DONOGHUE had a history of anxiety but in 2022 developed depression. He came under the care of the Home Based Mental Health Team (HBTT) following visiting the Humber Bridge with a wish to end his life on 7th May 2022. Mr Donoghue agreed to engage with HBTT and was awaiting an arranged handover to the Community Team. During this period, Mr Donoghue raised his concern at the lack of continuity of staff that were assigned to oversee his care plan. He specifically told HBTT that he would sometimes put on a front with new faces to make him look okay when he was struggling. The lack of continuity more than minimally hindered his ability to engage and receive the best level of care. On 24th May 2022,[REDACTED]. He was 33 years of age. � His medical cause of death was recorded as: 1a�Hanging

Mr Donoghue was an intelligent and high achieving individual who was part of a loving relationship. He had a history of anxiety but developed depression following the loss of his mother through suicide in January 2022, some childhood issues and frustrations over the care of his young poorly daughter. He had made previous attempts to end his life including using a ligature 4 years previously, an overdose on 28/02/2022, overdose attempts in April 2022. � On 7th May 2022 Mr Donoghue was taken by police to Miranda House (a place of support for mental health) after he attended the Humber Bridge with the intention to end his life. Mr Donoghue indicated to staff at Miranda House that he wanted help; he was assessed, did not want admission and opted for being treated by the Home Based Treatment Team (HBTT). � During May 2022 Scott spoke about hanging himself to his partner, [REDACTED].� � The HBTT conducted a series of visits while he awaited a date to be moved to the Community Mental Health Team where he would have had one person having oversight of his care. � Due to the need for 24 hour a day/7 days a week HBTT service, the court heard that continuity of care by either one person or a small group of people was not possible. Mr Donoghue raised concerns on more than one occasion about the lack of continuity of the people overseeing his care, he specifically told them that he could sometimes put on a front with new faces to make him look okay when he was actually struggling. � Mr Donoghue used a ligature and hanged himself at his home on 24th May 2022.

I have sent a copy of my report to: ����� The Chief Coroner ����� The family of Scott James DONOGHUE ����� The family of Hollie Louise TENNENT ����� The Humber Mental Health Trust ����� The ICB for Humber 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: Department of Health and Social Care

01/08/2024

2024-0445

Leah Croucher

Milton Keynes

Minister of State for Prisons, Parole and Probation

On the 1st of November 2022 I commenced an investigation into the death of Leah Shannon Croucher aged 19. The investigation concluded at the end of the inquest on the 19th of June 2024. The conclusion of the inquest was: Unlawful killing

On the morning of the 15th of February 2019 Leah left her home address to walk to work, however she never arrived. Later on the same day her family reported Leah as missing to the police. A police investigation followed but they were unable to locate or establish what had happened to Leah. On Monday the 10th of October 2022 Police were alerted to the presence of a body located in the loft of a Milton keynes house. The house was located on the route Leah would take to work. The body was subsequently identified as being Leah Croucher. A police investigation followed. The police confirmed that the circumstances and evidence supported that Leah Croucher had been abducted and murdered either on the day or shortly after she had gone missing. Strong evidence was obtained identifying an individual as the perpertrator. This person had died from suicide on the 20th of April 2019. He was a known repeat sex offender subject to supervison by the probation service and the police before, and at the time of the murder.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Chief Probation Officer England and Wales. Chief Constable Thames Valley Police. Croucher 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 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

HM Prison and Probation Service

07/02/2024

2024-0061

James Day

Manchester South

Ministry of Defence

On 9th May 2023 I commenced an investigation into the death of James Colin Day. The investigation concluded on the 26th October 2023 and the conclusion was one of Narrative: Died from health complications arising from use of alcohol and medication to try to deal with the complications of severe post-traumatic stress disorder caused by his service in the army. The medical cause of death was 1a) Acute Left Ventricular Failure; 1b) Left ventricular hypertrophy on background of alcohol-related liver disease with superimposed combined drug toxicity; II) Post-traumatic stress disorder

James Colin Day served his country. As a consequence of his deployment in Afghanistan he developed severe post-traumatic stress disorder. He was discharged from the army having received little support to help him deal with his post-traumatic stress disorder. He used alcohol to excess and prescribed medication to try and deal with his post- traumatic stress disorder. On 6th May 2023 he collapsed on Malvern Road, Old Trafford. Attempts to resuscitate him were unsuccessful. Post- mortem examination found he had developed alcohol related liver disease which had led to left ventricular hypertrophy and an acute left ventricular failure exacerbated by combined drug toxicity.

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

Service Personnel related deaths | Alcohol, drug and medication related deaths This report is being sent to: Ministry of Defence

13/08/2024

2024-0453

Joanita Nalubowa

Inner North London

Ministry of Housing, Communities and Local Government 2 Marsham Street� London� SW1P 4DF� United Kingdom

On 5 February 2021 the Senior Coroner, Mary Hassell, commenced an investigation into the death of Joanita Nalubowa, born in Uganda on 27th May 1990.� The investigation concluded at the end of the inquest on 5 August 2024.� On 25th December 2020 Ms Nalubowa suspended herself with a ligature, whilst an inpatient at the St Pancras Hospital in King�s Cross. She was� successfully resuscitated but sustained an hypoxic brain injury from� which she subsequently died.� The jury returned a conclusion of Misadventure, and found as follows in Box 3:� Death by hanging [REDACTED] The medical cause of death was 1a Hypoxic ischaemic encephalopathy 1b Asphyxiation by hanging�� 1c Severe major depression

(1) Immediately prior to her detention the Deceased had been living in Stockton in the North of England (near Middlesbrough).� (2) However she was now divorced with few ties to that area. (3) Moreover, importantly, concerns had been raised that the ex-partner in question was abusive.� (4) The Deceased�s family and support network was in London and not Stockton.� (5) Returning to Stockton was a source of great anxiety for the� Deceased. She commented that she would �rather die than return to Middlesbrough [sic]�.� (6) It was clear to treating clinicians that securing the right� accommodation was paramount to her mental health prognosis and to her future more generally.� (7) It was clear to treating clinicians that surrounding the Deceased with a positive supportive network of family was crucial in� maintaining mental health.� (8) Despite all of the above, the existing framework/rules were such that all London boroughs, correctly applying the relevant criteria, rejected the Deceased�s applications for accommodation in� London.�� (9) The witness evidence was clear that there was no �discretion� and that London Boroughs and treating clinicians alike were�powerless. The Deceased was therefore discharged to Stockton,� against her wishes, against medical advice, away from her�support network, and to an area where she would have to at best� face her demons and at worst be in physical danger.� (10) Shortly after being told she was being discharged to Stockton, the Deceased suspended herself using a ligature.

I have sent a copy of my report to the following. [REDACTED]� Minister of State at the Ministry of Housing, Communities and Local Government Stockon on Tees Borough Council Camden and Islington Trust (�CANDI�) The Chief Coroner of England & Wales I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� I may also send a copy of your response to any other person who I believe may find it useful or of interest.�� The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.

�Suicide (from 2015)

Ministry of Housing, Communities and Local Government

22/01/2025

2025-0038

Nathan Shepherd

Manchester South

Ministry of Justice

On 17th January 2024 I commenced an investigation into the death of Nathan� Harry SHEPHERD. The investigation concluded at the end of the inquest on 20th December2024. The conclusion of the inquest was suicide and the medical� cause of death was 1a) Hypoxic brain injury 1b) Hanging.

Nathan Harry Shepherd had a history of mental health issues and drug use.� Whilst in custody in 2023 he was subject to an ACCT following him taking an� excess amount of medication in his cell. His calls were recorded from June 2023� and indicated he was using drugs and that his mental health fluctuated. On 8th� January 2024 he was released from custody to approved premises at Ascot� House. He was allocated a single room at Ascot House, he did not indicate any� immediate thoughts of suicide or self-harm to staff. The full extent of his mental health history and ACCT history was not known to the staff at Ascot House. This� was due to poor information sharing by probation service staff, this probably� did not contribute to his death. On 11th January 2024 he sent a series of� messages to other residents which demonstrated he was deteriorating. Staff� were unaware of those messages. Ascot House overnight was staffed by one� member of probation and an agency worker. Both were required to be first aid� trained. On 11th January a text message was sent by Nathan Shepherd to the� landline in the office at Ascot House. It caused the phone to ring and the� message said the door was blocked and he was hanging. It was acted on by the� member of staff going straight to Nathan Shepherd�s room. An attempt to gain� entry was unsuccessful because he had barricaded himself into the room. The� barricading of entry to the room was made possible because the furniture was� moveable. Attempts were made to force entry. After approximately 12 and a�half minutes, entry was gained, and Nathan Shepherd was found suspended� from a ligature. Entry would have been gained immediately had he not been� able to barricade himself into his room. The staff cut the ligature on entry�releasing the compression and began CPR. Paramedic assistance arrived� approximately within 10 minutes after the staff gained entry. CPR continued� along with attempts to intubate him. Intubation was unsuccessful until the� arrival of a critical care paramedic. Successful intubation was followed by a� return of spontaneous circulation at 06:38. He was transported to Stepping Hill Hospital where a CT scan 08:35 showed extensive loss of grey-white matter� differentiation indicating an anoxic brain injury. He was moved to the critical� care unit. On 15th January a further scan showed that the position had� deteriorated further and he had a hypoxic brain injury that was not compatible with life. He died at Stepping Hill Hospital on 16th January 2024.

I have sent a copy of my report to the Chief Coroner and to the following� Interested Persons mother of Mr Shepherd on behalf of the family. I have also sent it to GMP, Prisons & Probation Ombudsman (PPO), HMP Berwyn &� Probation Services 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. They may send a copy of this report to any person who they� believe may find it useful or of interest. You may make 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) | State Custody related deaths

Ministry of Justice

16/05/2024

2024-0270

Luke Pearce

Staffordshire and Stoke on Trent

Ministry of Justice His Majesty�s Prison and Probation Service (HMPPS) The Governor of HMP/YOI Swinfen Hall

On 12 April 2023 I commenced an investigation into the death of Luke Mikael PEARCE aged 21. The investigation concluded at the end of the inquest on 16 May 2024. The conclusion of the inquest was that: suicide.

Mr Luke Pearce was found hanging in his cell on 6 April 2023, at HMP/YOI Swinfen Hall. He was 21 years old. Mr Pearce had given no indication to staff that he was at risk of suicide or self harm in the months leading up to his death. � Shortly after 5.30am on 6 April 2023, during a routine check, [REDACTED]. The officer called to Mr Pearce but got no response. He looked through the crack of the door and saw Mr Pearce with a ligature around his neck. The officer radioed for urgent assistance but did not use the appropriate coded wording of �Code Blue�. � An Operation Support Grade attended and briefly entered Mr Pearce�s cell before coming out again. When another officer attended, the first officer and OSG told her that she should not enter the cell as it was a crime scene. She contacted a custodial manager for permission to go in and then cut the ligature and lowered Mr Pearce to the floor. The officer and OSG waited outside and did not assist. � At 5.40am, more staff arrived and the control room staff called an ambulance. Staff started CPR at 05.42am. Ambulance paramedics arrived at 5.59am and took over CPR. At 6.30am, they pronounced that Mr Pearce had died. � There was a delay in staff entering the cell, removing the ligature and starting CPR. This did not contribute towards Mr Pearce�s death.

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

Suicide (from 2015) This report is being sent to: Ministry of Justice | HM Prison and Probation Service | Swinfen Hall

21/02/2023

2023-0066

Andrew Still

Gwent

Monmouthshire County Council � � [REDACTED] Chief Executive � [REDACTED] Council Leader

INVESTIGATION AND INQUEST � On 14/6/2022 an investigation was opened into the death of Andrew Mark STILL. The investigation concluded at the end of the inquest on: 15/02/2023. The conclusion of the inquest was recorded as: Road Traffic Collision The medical cause of death was: 1a. Multiple injuries 1b. Blunt vehicular trauma

On 03/06/2022 Andrew Mark Still was riding his motorcycle on the A466 towards Chepstow from Tintern. � Approximately 1 mile from the village of Tintern, Andrew encountered a double bend. As he rode into the second bend, Andrew was on the wrong side of the road and collided with a VW campervan travelling in the opposite direction. Andrew suffered extensive injuries and died at the scene.

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

Road (Highways Safety) related deaths

Monmouthshire County Council

20/10/2023

2023-0401

Jill Brice

West Sussex, Brighton and Hove

Mr. Michael GOVE MP Secretary of State for Housing [REDACTED] Chief Executive Care Quality Commission

On 04 January 2023 I commenced an investigation into the death of Jill BRICE aged 93. The investigation concluded at the end of the inquest on 18 October 2023. The conclusion of the inquest was that:

Jill Brice died on the 23rd of December 2022 at Royal Sussex County Hospital in Brighton. She was in sheltered housing in the Dene (Housing Association property). The extractor fan in her residence Flat 29, the Dene, The Green, Rottingdean, Brighton caught fire causing her to suffer burn injuries and smoke inhalation from which she died. Mrs. Brice was not wearing her emergency pendant when she died. The Fire Safety Report (attached) recommended that care residents be reminded to have their pendant close to them at all times. I would like reassurance that this be actioned.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � 1. [REDACTED] 2.������ East Sussex Fire & Rescue 3.������ Secretary of State for Health 4.������ Chief Executive NHS England 5.������ Teacher Housing Association � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

Other related deaths This report is being sent to: Department for Housing | Care Quality Commission

25/03/2024

2024-0172

Patricia Eyken

Cornwall and the Isles of Scilly

Ms Victoria Atkins MP, Secretary of State for Health & Social Care

On 29 September 2023 I commenced an investigation into the death of Patricia Anne Van Der Eyken. The investigation concluded at the end of the inquest on 11 March 2024. � The medical cause of death was found to be as follows: � 1a Malignant Acute Cardiac Arrhythmia � 1b Coronary Artery and Systemic Atherosclerosis � � The four questions � who, when, where and how � were answered as follows: � Patricia Anne VAN DER EYKEN died on 13 September 2023 at Rivercourt 5 East Bridge Chacewater Truro Cornwall from cardiac arrhythmia due to atherosclerosis following an ambulance delay which more likely than not contributed to Patricia�s death by preventing the administration of life saving treatment. � The conclusion of the Inquest was that Patricia died from an (untreated) heart attack following an ambulance delay which likely contributed to Patricia�s death by preventing the administration of life saving treatment.

Patricia was 93 years old at the date of her death. Her medical history indicated that Patricia was fit and well for her age. � In the early hours of 13 September 2023 Patricia called 999 reporting symptoms of a heart attack, namely a sharp pain in her chest, and down her left arm. � Following the 999 call, South West Ambulance Service Trust (SWAST) determined a Category 2 response requirement. Category 2 identifies potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. The national response time as set by the Department of Health is to attend Category 2 incidents within an average response time of 18 minutes, and at least 90% of incidents within 40 minutes. � The ambulance arrived on scene after a delay of two hours and 37 minutes from the time of the �999� call by Patricia. Patricia was found deceased by the ambulance crew. � The court heard evidence of the post-mortem which indicated that Patricia died following cardiac arrhythmia due to atherosclerosis. The court heard evidence from a medical examiner regarding Patricia�s death. The medical examiner stated that the original description of chest pain radiating to the left arm is strongly suggestive of myocardial ischaemia. The court found that there are a range of appropriate treatments for conditions such as those reported by Patricia. This included the availability of treatment to prevent the subsequent arrhythmia that led to Patricia�s death. The court found that if Patricia had been admitted to hospital promptly, that it is likely that appropriate treatment would have prevented Patricia�s death. � The court found that the categorisation of the call by ambulance services was appropriate. � The court found that the delay was not caused by any individual failing but was attributable to a systemic failure discussed in the concerns set out below.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family and SWAST. � I have also sent a copy to Royal Cornwall Hospital Truro , University Hospital Trust Plymouth and Cornwall 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.

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

25/03/2024

2024-0166

Robert Prowse

Cornwall and the Isles of Scilly

Ms Victoria Atkins MP, Secretary of State for Health & Social Care

On 25 September 2023 I commenced an investigation into the death of Robert Andrew PROWSE. The investigation concluded at the end of the inquest on 18 March 2024. � The medical cause of death was found to be as follows: � 1a. Urosepsis � 2 Frailty of Old Age � The four questions � who, when, where and how � were answered as follows: � Robert Andrew PROWSE died on 19 September 2023 at Royal Cornwall Hospital Truro Cornwall from sepsis following an ambulance delay, attributable to a systemic failure, which is likely to have contributed to Robert�s death by preventing lifesaving treatment. � The conclusion of the inquest was that Robert died from sepsis contributed to by an ambulance delay, attributable to a systemic failure, which likely prevented lifesaving treatment.

Robert was 86 years old at the date of his death. His medical history included a diagnosis of dementia. � In the early hours of 19 September 2023 Robert�s neighbour called 999 on his behalf advising that Robert had been found breathing but not conscious, and it looked like he had had a seizure. � Following the 999 call South West Ambulance Service Trust (SWAST) determined a Category 2 response requirement. Category 2 identifies potentially serious conditions that may require rapid assessment, urgent on-scene intervention and/or urgent transport. The national response time as set by the Department of Health is to attend Category 2 incidents within an average response time of 18 minutes, and at least 90% of incidents within 40 minutes � The ambulance arrived on scene after a delay of three hours and 47 minutes from the time of the original 999 call. � The ambulance arrived at Royal Cornwall Hospital Truro (Treliske) but it was not possible to transfer Robert to the emergency department (ED) due to the lack of available space. The court heard evidence of crowding within ED which included patients being placed in corridors. � Robert was instead taken from the ambulance to a triage centre adjacent to Treliske ED. The triage centre is known as the Rapid Assessment and Treatment Centre. There it was noted that Robert displayed evidence of sepsis but it was determined that his condition was not immediately life threatening. Robert was given fluids but not antibiotics and then returned to the ambulance parked outside ED. � Robert remained in the ambulance attended by the paramedic crew until later transfer to ED at 11:05 hours. The delay in handover between ambulance and Treliske ED was one hour, 25 minutes. There is a target for crews to handover the care of their patients within 15 minutes of arriving at an Emergency Department. � Robert was then subject to tests and sepsis was identified. Robert was found deceased at 13:00 hours. Antibiotics had been prescribed but Robert died before they could be administered. � The court heard evidence from [REDACTED] that the ambulance delay, including response delay and handover delay, likely contributed to Robert�s death. This is because earlier treatment of sepsis is likely to avoided Robert�s death. [REDACTED] stated that early treatment of sepsis by way of oxygen, antibiotics and fluids, saves lives and improves outcomes. In Robert�s case earlier treatment is likely to have made a difference to the outcome. � The court found that the categorisation of the call by ambulance services was appropriate. � The court found that the delay was not caused by any individual failing but was attributable to a systemic failure discussed in the concerns set out below.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family, SWAST and Royal Cornwall Hospital Truro (Treliske). � I have also sent a copy to University Hospital Trust Plymouth (Derriford), [REDACTED], and Cornwall 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.

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

23/11/2023

2023-0473

Kenneth Heard

Cornwall and the Isles of Scilly

Ms Victoria Atkins MP, Secretary of State for Health & Social Care

On 12 July 2022 I commenced an investigation into the death of 79-year-old Kenneth Heard. The investigation concluded at the end of the inquest on 31 October 2023. � The medical cause of death was found as follows: � 1a Cardiac Arrest 1b ST Elevation Myocardial Infarction II Hypertension, Hypercholesterolemia, Psoriasis � The four statutory questions � who, when, where and how � were answered as follows: Kenneth HEARD died on 11 July 2022 at Royal Cornwall Hospital Truro from an untreated heart attack leading to cardiac arrest before surgical procedures could be commenced which would have significantly increased Kenneth�s prospect of survival. The heart attack was untreated due to an eight-hour delay in the arrival of the ambulance, it being more likely than not that Kenneth would have survived but for that delay. � My conclusion as to Kenneth�s death was as follows � Kenneth Heard died from a cardiac arrest following a heart attack which was untreated due to an ambulance delay.

On 10 July 2022 Kenneth had a major heart attack, symptoms starting from 2pm that day. He had no relevant medical history excepting a report of chest pains three weeks before his death. � Kenneth�s wife, [REDACTED] , made a 999 call at 16:55 hrs on 10th July 2022. The call was triaged as category 2 priority. The national target set by the Department of Health is to attend Category 2 incidents within 40 minutes on at least 90% of occasions, with an average response of 18 minutes. � The ambulance arrived the following day, 11 July 2022 at 01:05:59hrs, giving a response time of 8 hours, 10 minutes from the original 999 call. � Treliske hospital (Royal Cornwall Hospital Trust in Truro), were pre-warned about Kenneth�s condition and the surgical team were in theatre ready to perform an operation to insert a stent. However, Kenneth suffered a cardiac arrest on arrival at Treliske. The surgical team were summoned to assist with resuscitation. Medical teams attempted resuscitation for 47 minutes, but this was unsuccessful. � On the basis of evidence from the cardiologist, the court found that early treatment within 2 hours of a heart attack leads to significantly improved chances of survival. Surgery within 2 hours, leads to a 95 % survival rate. The court found that on a balance of probabilities it is more likely than not that Kenneth would have survived but for that ambulance delay.

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

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

07/06/2024

2024-0311

Fern Foster

Buckinghamshire

NATIONAL AMBULANCE RESILIENCE UNIT (NARU) NATIONAL AMBULANCE SERVICE MEDICAL DIRECTORS (NASMeD) ASSOCIATION OF AMBULANCE CHIEF EXECUTIVES (AACE) NHS ENGLAND (NHS Pathways)NATIONAL CODING GROUP (Central Ambulance Team) EMERGENCY CALL PRIORITISATION ADVISORY GROUP (ECPAG)

On 15th July 2020 I commenced an investigation into the death of Fern Elisabeth Foster, aged 22. The investigation concluded at the end of the inquest on 18th April 2024. The medical cause of Fern�s death was [REDACTED] A narrative conclusion was recorded: �Suicide to which the following contributed more than minimally: (a) Fern Foster did not have access to independent advocacy from an early stage in 2019, and thereafter on a regular, consistent and continuous basis, nor on the 8th July 2020 when she learned of significant news likely to trigger suicidal intention; (b) the manner in which Fern learned of the significant adverse news, in the absence of physical professional support, probably caused Fern to act as she did, at the time she did, with the intention of ending her life.�

Fern Foster�s death was verified at around 15:20 on 8th July 2020 at her current accommodation. Fern had received news that day concerning the intended adoption of her child in circumstances where professional support, including independent advocacy, was not physically present at the time to try to assist Fern with processing the information, to safeguard her mental wellbeing and to address her likely increased risk of suicide. Fern had previously indicated her intention to end her life, were her child to be adopted, and had also taken two overdoses in March with the likely intention of ending her life, although she received treatment and survived on both occasions. Fern had procured a different substance at the end of March and when, on 8th July 2020, she consumed some of the contents from the package in her possession, she intended her death to result. Fern had a pre-existing, well-established, accepted, and recognised diagnosis of Autism Spectrum Disorder

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Family of Fern Foster [REDACTED] South Central Ambulance Service Thames Valley Air Ambulance Buckinghamshire Council Adult Services Buckinghamshire Council Children�s Services Oxford Health NHS Foundation Trust � I have also provided a copy to: Thames Valley Police Buckinghamshire Safeguarding Adults Board � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: National Ambulance Resilience Unit | NATIONAL AMBULANCE SERVICE MEDICAL DIRECTORS | Association of Ambulance Chief Executives | NHS England

20/04/2023

2023-0127

Chester Mossop

Cumbria

NATIONAL HEALTH SERVICE OFFICE OF PRODUCT SAFETY AND STANDARDS

Chester Alan Stanley MOSSOP died on 3 June 2022 following an incident at his home address on 29 May 2022. Baby Chester�s death was reported to HM Coroner for Cumbria on 6 June 2022 and his death formally transferred from HM Coroner Newcastle. An investigation into his death (in accordance with Section 1 Coroners and Justice Act) was commenced on the same day. � An inquest into Chester�s death was opened on 23 February 2023 and his inquest was heard before me on 13 April 2023. � The medical cause of Chester�s death was: � 1a Hypoxic ischaemic brain injury 1b Cardiac arrest (resuscitated) 1c Drowning � The determination was: � Chester Alan Stanley Mossop was a healthy and well-looked after 9 months� old baby. On 29 May 2022, Chester was placed in a bath seat in a bath of warm water at his home. After approximately 20 minutes of bath time, Chester was left alone in his bath seat. After a few minutes, Chester was found face down in the bath, the bath seat having become unfixed. Chester was given immediate CPR which was continued by attending police, paramedics and clinicians. Chester was conveyed to the Great North Children�s� Hospital at the Royal Victoria Infirmary by air ambulance. Everything was done to try to save Chester�s life. However, an MRI scan showed that Chester had sustained an unsurvivable brain injury due to drowning and he died in his mother�s arms on 3 June 2022 at 18:05 at the Royal Victoria Infirmary. � The conclusion of the inquest was: � Accidental Death � I rejected, giving full reasons, a submission that Chester�s death was due to neglect and I made no finding in that respect. � I rejected, giving full reasons, a submission that Chester�s death was due to unlawful killing (by gross negligence manslaughter).

Chester was a healthy and well looked after 9 months� old baby. He was usually fit and well. However, on 29 May 2022, he had a mild viral infection (which was confirmed at post-mortem). � Chester was placed in a bath seat and given a bath in suitably warm water. The water level was higher than advised � so that Chester did not get chilled. � After about 20 minutes of bath time, Chester was left alone in his bath seat whilst a plug- in diffuser (to help his cold) was prepared in his bedroom. It was believed that the bath seat was safe and secure to hold him in place. � After a few minutes, Chester was found face down in the bath. The bath seat had become unfixed. There were no sounds that Chester was in distress or difficulty. He was immediately removed from the bath and given immediate CPR by a trained adult. Emergency services were quickly on scene and CPR was continued by police, paramedics and clinicians. Return of spontaneous circulation was achieved. � Chester was flown by air ambulance to the Great North Children�s Hospital at the Royal Victoria Infirmary in Newcastle. However, an MRI scan undertaken on 2 June 2022 showed that Chester had an extensive severe brain injury consistent with severe global hypoxic ischaemia caused by drowning. It was considered that Chester was unlikely to survive and further intensive care treatment was not in his best interest. � Intensive care support was withdrawn on 3 June 2022 and Chester died peacefully in his mother�s arms at 18:05. � I received a statement from RoSPA (the Royal Society for the Prevention of Accidents) setting out that: � ������� Baby bath seats are unstable and prone to toppling over leaving the baby trapped in the water. ������� Bath seats may give parents and carers a false sense of security that baby is safer in a bath seat and can be left alone (despite warnings that this should not happen). ������� There can be a misconception that a baby bath seat is a safety product � this is not the case. ������� Under no circumstances should parents regard bath seats as a safety aid and leave a child out of arms reach. ������� RoSPA is aware of incidents where parents have been in the room, but away from the baby, with tragic results. ������� RoSPA is aware of a number of drownings of young children in the bath where a baby bath seat has been used. ������� There may be some bath seats that are less stable than others or that have inadequate methods to hold them in place. I heard no evidence about any safety concerns with the bath seat in question. � The Child Death Overview Panel (�CDOP�) advised me that a Bath Safety Alert had been issued in the North-East and North Cumbria. This can be viewed at: � www.nenc-healthiertogether.nhs.uk/parentscarers/keeping-your-child-safe/bath-safety- advice � I requested an update on several matters but these were not available at the date of Chester�s inquest. Given the �ancillary nature� of Reports to Prevent Future Deaths and to avoid the distress of an adjournment to Chester�s family, I decided to proceed with the inquest.

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

Child Death (from 2015) This report is being sent to: National Health Service and Product Safety and Standards

25/04/2024

2024-0222

Erik Marshall

South Yorkshire West

NHS Cheshire and Merseyside Integrated Care Board 1 Lakeside 920 Centre Park Square Warrington, WA1 1QY.

On 18 October 2023 an investigation was commenced into the death of Erik Leigh Marshall, a 17 year old male born in Warrington. The investigation concluded at the end of the inquest on 25 April 2023. The conclusion of the inquest was death by misadventure. The medical cause of death was: 1a. Asphyxiation 1b. ligature hanging 2 ASD ADHD anxiety.

Erik Marshall died on 30 September 2023 at his home address [REDACTED] in Cheshire. He was found suspended by a ligature [REDACTED] Prior to this he had suffered from ADHD, mental health issues and had recently received a clinical diagnosis of autism. Erik�s sensory needs and mental health presentation meant that he habitually partly drowned himself in the bath [REDACTED] to experience a buzz and the feeling of numbness in his arms and legs. � Erik�s mental health needs were being treated in the community following an inpatient admission at ancorra house and the Priory. During admission to the Priory Erik was clinically diagnosed with autism. Following discharge from the Priory the plan was to obtain a sensory assessment through OT in the community�to�help him with�the�high�risk�sensory��behaviours.�The Child Development�Centre�CDC, art� of�Bridgewater�Community Healthcare NHS Trust, were invited to the CPA meetings and were aware of Erik. Referrals were made to the CDC for an ADOS assessment and OT input in May 2023. The CDC responded to state they did not require an ADOS assessment to provide the support but they did want to review the assessment undertaken at the Priory to see if this complied with NICE guidance before any referral to their nurses was made. They also made a decision, based on the limited information that they had been provided and without speaking to any clinician or family member, that Erik�s mental health need was more prominent than the sensory need. The CDC were still waiting for further information regarding the autism assessment in the Priory in August 2023, yet made no attempt to chase this up. I received evidence that escalations were made for specialist input for his sensory needs because it was identified without this it was likely to deteriorate and his risk increase. The OT referral was not accepted because of Erik�s age and that� whilst he was signposted to adult services these would only assist when he was 18 because there was a commissioning gap. Following escalation to the ICB specific funding was put in place for access to the sensory hive for Erik but the initial appointment only occurred on 22 September 2023 and Erik was found deceased in the back garden of his home 8 days following this.

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

Child Death (from 2015) | Suicide (from 2015) This report is being sent to: Cheshire and Merseyside Integrated Care Board

19/04/2024

2024-0207

Richard Hardman

Manchester South

NHS ENGLAND GREATER MANCHESTER INTEGRATED CARE

On 10th August 2023, an investigation was commenced into the death of Dr Richard George Hardman, aged 77 years. The investigation concluded at the end of the inquest on 20th March 2024. The conclusion of the inquest was that the medical cause of death was: � 1a) Aspiration Pneumonia 1b) PEG feeding 1c) Oropharyngeal Dysphagia due to Bulbar Myopathy due to radiotherapy for Tonsillar Cancer (2001) and Parkinson�s disease � The conclusion as to his death was that he died from aspiration pneumonia which arose as a result of a combination of natural disease and recognised effects of necessary medical treatment.

Dr Hardman underwent radiotherapy in 2001 for tonsillar cancer and after a number of years developed dysphagia which was later found to be a late onset side effect of the cancer treatment. � He was at risk of aspiration due to hypersalivation and mucus secretions, such that a PEG tube was inserted in July 2022 to mitigate the risk. He developed symptoms of and was diagnosed with Parkinson�s disease by a consultant neurologist. Parkinson�s disease further compromised his ability to swallow and breathe. � By May 2023, his respiratory system was significantly compromised, he was under the care and supervision of the North West Ventilation Unit (NWVU). � There were difficulties in identifying both the provider of a suction machine and training in the use of a suction machine at home, as he did not live within the immediate geographical area of the NWVU from which the recommendation for a suction machine came with the result that the machine was unavailable for a period of about a month. Dr Hardman then suffered a spontaneous sigmoid volvulus which was resolved as an in- patient, but without surgical intervention. � On 7th August 2023, Dr Hardman became unwell and on admission to hospital, was found to have aspiration pneumonia and a partial sigmoid volvulus confirmed at post- mortem. � The evidence in the inquest strongly suggested undetected gastroparesis and the post-mortem examination revealed evidence of chronic aspiration. � There were a number of different medical disciplines involved in Dr Hardman�s treatment and care across a number of different NHS hospitals, but the absence of any lead practitioner meant that there was no global oversight of the various complex interacting conditions and care and whilst the inquest did not find evidence to say, had such a lead practitioner been in place, that Dr Hardman�s life would have been prolonged or saved, the potential for more collaborated, holistic care was clearly apparent which could in patients with complex multi-disciplinary needs, prevent death.

I have sent a copy of my report to the Chief Coroner and to the following Interested Person: [REDACTED] on behalf of Dr Hardman�s family. I am also sending copies to the Chief Executives of the Manchester University NHS Foundation Trust and the Stockport 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 | Greater Manchester Integrated Care

19/07/2023

2023-0254

Evelyn Dutton Coroner name: Alison Mutch Coroner Area: Manchester South Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: NHS England

NHS England

On 19th August 2022 I commenced an investigation into the death of Evelyn Mary Dutton. The investigation concluded on the 4th May 2023 and the conclusion was one of Narrative: Died from natural causes contributed to by complications of an accidental fall, poor nutritional status and complications of necessary medication. The medical cause of death was 1a) Multi-organ failure; 1b) Frailty; II) Multiple Duodenal Ulcers, Fracture left hip with Hemiarthroplasty, Poor Nutritional Status, Systemic Sclerosis

Evelyn Mary Dutton had severe Systemic Sclerosis. She was admitted to Stepping Hill Hospital following an accidental fall at her home address. It was identified that she had fractured her neck of femur. She was operated on. Post-operatively her weight was found to be low and she was referred to the dietetics team. Her nutritional status remained compromised and an Nasojejunal (NJ) tube was sited on 21st July 2022. There was a delay in utilising the NJ Tube until 29th July. The NJ feeding was subsequently stopped due to concerns of aspiration and fluid overload. It was restarted on the night of 4th August. There was a significant electrolyte imbalance, probably due to refeeding syndrome due to the issues with nutrition. On 5th August the feeding via the NJ Tube was stopped due to episodes of vomiting of blood from her gastro intestinal issues including duodenal ulcers, identified in a series of gastroscopies, probably caused by steroid treatment. She continued to become increasingly frail. She deteriorated further and died at Stepping Hill Hospital on 13th August 2022.

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

20/07/2023

2023-0262

Marianne Erika

Manchester South

NHS England

On 28th December 2022 I commenced an investigation into the death of Marianne Erika Oldham. The investigation concluded on the 6th June 2023 and the conclusion was one of Narrative: Died from the complications of a perforation of the sigmoid colon where the perforation was not identified until 12 hours after her arrival in the Emergency Department and treatment was delayed as a consequence. The medical cause of death was 1a) Peritonitis; 1b) Stercoral Perforation of Sigmoid Colon; 1c) Intra-abdominal Adhesions; II) Ischaemic Heart Disease

Marianne Erika Oldham was admitted via ambulance to the Emergency Department at Tameside General Hospital on 16th December at 17:33. She was triaged at 17:52. She presented with a history of vomiting and abdominal pain. She was triaged into Category 3 (urgent) which recommends clinical assessment within 60 minutes. She was not clinically assessed until 02:46 � 9 hours after her arrival. The delay was due to the demand on the department and was not unusual at that time. The abdomen was distended and guarded. A decision was made that she needed antibiotics and a CT scan. The antibiotics were not prescribed until 04:21 and administered at 04:50. The CT scan was ordered at 04:13. The delay was due to the clinical demands on the department. The scan took place at 05:11 and at 05:44 it was reported on. The scan showed a sigmoid colon perforation. She was referred to the surgical team who saw her at 06:50. A conservative treatment plan was put in place. She was moved to a surgical ward where she began to rapidly deteriorate with her NEWS 2 score rising to 16 at 08:55. Her NEWS 2 had been 1 at triage and 3 at 23:53 and 04:13. She died at Tameside General Hospital on 17th December just after 9am from peritonitis.

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

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

20/07/2023

2023-0263

Albert Dovey

Manchester South

NHS England

On 10th February 2023 I commenced an investigation into the death of Albert Dovey. The investigation concluded on the 30th June 2023 and the conclusion was one of Narrative: Accidental death exacerbated by underlying heart failure. The medical cause of death was 1a) Frailty; 1b) Rhabdomyolysis and fractured clavicle; 1c) Fall; ) II Heart failure, Acute kidney injury

Albert Dovey had an accidental fall in his home address. He was found on the floor at his home address. He was admitted to Tameside General Hospital where he was found to have rhabdomyolysis. His oxygen requirement was significant. He had an acute kidney injury and required a blood transfusion. He had heart failure. He was treated with antibiotics. He was found to have fractured his clavicle which further reduced his mobility. He became gradually frailer as a consequence of his reduced mobility in combination with his heart failure despite treatment. On 4th February 2023 he died at Tameside General Hospital.

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

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

12/03/2024

2024-0135

Elizabeth Brown

Manchester South

NHS England

On 26th January 2023 I commenced an investigation into the death of Elizabeth Jane Brown .The investigation concluded on the 18th May 2023 and the conclusion was one of Narrative: Died from mesothelioma caused on the balance of probabilities by exposure to asbestos the precise source of which cannot be ascertained. The medical cause of death was 1a) Mesothelioma ; 2) Chronic Obstructive Pulmonary Disease

Elizabeth Jane Brown had significant respiratory health issues including severe Chronic Obstructive Pulmonary Disease. In November 2022 a CT scan raised a suspicion of mesothelioma. Further tests and discussion confirmed that on the balance of probabilities she had mesothelioma caused by asbestos exposure. The source of the asbestos exposure could not be established. She deteriorated rapidly and died at Stepping Hill Hospital on 23rd January 2023 from mesothelioma.

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) 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: NHS England

20/10/2023

2023-0394

Kirsty Hendry

Manchester South

NHS England

On 18th April 2023 I commenced an investigation into the death of Kirsty Michelle Hendry. The investigation concluded on the 8th September 2023 and the conclusion was one of Narrative: Died from the complications of a subarachnoid haemorrhage caused by a burst aneurysm which was not diagnosed until vasospasms had severely compromised her neurological status and she could not be successfully treated. The medical cause of death was 1a) Cerebral Infarction; 1b) Vasospasm; 1c) Spontaneous Subarachnoid Haemorrhage

On 30th March 2023 Kirsty Michelle Hendry was seen at her surgery by an advanced nurse practitioner. She presented with a headache and vomiting which had started two days previously. She was prescribed antibiotics for a suspected infection. It is probable that the symptoms were due to a subarachnoid haemorrhage due to a burst aneurysm. A hospital referral at this point would probably have identified the subarachnoid haemorrhage and allowed preventative treatment to reduce the risk of her developing severe vasospasm. On 2nd April 2023 an ambulance was called as she was feeling unwell. The ambulance crew did not recognise that her behaviour was inconsistent with her usual presentation. She was taken to Tameside General Hospital where there was a prolonged wait to be seen. A CT scan undertaken showed evidence of a subarachnoid haemorrhage that had occurred previously around 28th March 2023. The scan was incorrectly reported as being clear. At Tameside General Hospital her consciousness levels were reduced, and she was agitated. She had probably developed a severe vasospasm from the subarachnoid haemorrhage. Treatment options at this point are extremely limited. An MRI scan on 5th April 2023 showed multi territorial infarctions and significant narrowing of all the intracranial vessels. On the balance of probabilities, the neurological situation was probably irreversible on her admission to Tameside General Hospital. She was transferred to Salford Royal Hospital where attempts to treat her were unsuccessful. She died at Salford Royal Hospital on 11th April 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) [REDACTED] on behalf of the Family and; 2) Tameside and Glossop Integrated Care 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

07/08/2024

2024-0448

Martyn Stringer

Oxfordshire

NHS England

On the 5 April 2023 an Inquest was opened into the death of Martyn Harvey Stringer� who died on the 29 March 2023. On the 25 July 2024 I concluded an Inquest into his death at the end of a 3-day hearing.

The immediate circumstances are that: On 24 March 2023, Martyn was�detained by police in Sussex after being found at�[REDACTED] where he had�ostensibly gone to take his own life. He was taken to Eastbourne District�General Hospital.� There he was assessed and deemed liable for detention under Section 2 of the Mental Health Act. However, there were no available mental� health beds nationally and a suitable placement could not be found for him.� Having been at the hospital since Friday evening, he contacted family members� on Sunday, 26 March who collected him and brought him back to his home in� Oxfordshire. On 27 March 2023, Martyn left his home and stepped in front of a lorry on the� A4074. Witnesses described his actions as deliberate.� The medical cause of �death was determined following a post-mortem examination to be multi-organ failure and polytrauma resulting from a road traffic collision.

I have sent a copy of this report to: The family of Mr Stringer Oxfordshire ICB� East Sussex ICB� � 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)

NHS England

01/12/2023

2023-0491

Anthony Williams

Manchester South

NHS England

On 3rd May 2023 I commenced an investigation into the death of Anthony Eric Williams. The investigation concluded on the 27th September 2023 and the conclusion was one of Narrative: Died from the complications of bowel cancer not diagnosed and not treated until it had reached an advanced stage. The medical cause of death was 1a) Metastatic Adenocarcinoma of the bowel

Anthony Eric Williams presented at Tameside General Hospital with abdominal pain and was diagnosed with constipation on 7th October 2022.On 12th October a telephone consultation with a GP resulted in further discussion of treatment for constipation. On 3rd November he was found by the GP to have a distended abdomen and was referred on the two-week cancer pathway. CT scans found a mass in his bowel. Biopsies were initially inconclusive for cancer. A PET scan on 8th February confirmed advanced colorectal cancer. A stoma was inserted laparoscopically on 14th February to assist with his bowel symptoms. He was not seen for chemotherapy consideration until 6th March 2023. His health had deteriorated significantly since his referral on the cancer pathway and his suitability for chemotherapy was borderline. The plan was to start it around 17th March. In the period he developed spinal cord compression and received radiotherapy which was given on 21st March. He continued to deteriorate with the cancer having spread into his brain. Chemotherapy was not started until 4th April 2023.He deteriorated rapidly with the cancer having spread aggressively. He died at Stamford Court on 28th April 2023.

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

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

17/10/2023

2023-0390

Holly Mullan

Manchester South

NHS England

On 9th May 2023 I commenced an investigation into the death of Holly May Mullan. The investigation concluded on the 29th September 2023 and the conclusion was one of Narrative: Died from the complications of suspension from a ligature whilst under the influence of alcohol. The medical cause of death was 1a) Hanging

Holly May Mullan had longstanding severe abdominal pain. She had long delays waiting for medical appointments to see gynaecologists and gastroenterologists due to long waiting lists. At times she accessed private consultations to try and obtain insight into and relief from her pain. On 7th May 2023 Holly May Mullan was found at 3 Napier Road attached to a ligature. Police enquiries found no suspicious circumstances and no evidence of third-party involvement. Post-mortem examination found she was significantly under the influence of alcohol at the time of her death.

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.

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

09/10/2023

2023-0378

Sandra Curran

Manchester South

Foreign, Commonwealth and Development Office ABTA � The Travel Association

On 14th July 2022 I commenced an investigation into the death of Sandra Curran. The investigation concluded on the 5th June 2023 and the conclusion was one of Accidental Death. The medical cause of death was 1a) Apshyxia; 1b) Drowning

On 4th July 2022, Sandra Curran was snorkelling in the sea adjacent to the beach in Bugibba Saint Paul�s in Malta. Concerns were raised about her appearing to be no longer moving. She was brought to the beach where she was unresponsive. An investigation in Malta found she had died from asphyxia as a consequence of drowning.

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

Other related deaths This report is being sent to: Foreign, Commonwealth and Development Office | ABTA � The Travel Association

26/04/2024

2024-0226

Ellen Mercer

Berkshire

Frimley Health NHS Foundation Trust National Institute of Clinical Excellence NHS England

The family requested me to refer to the deceased as Ellen. I will reflect that in this report. Ellen was 24 at the time of her death. � I conducted an inquest into the death of Ellen Mercer which concluded on 10th of April 2024. I recorded a narrative conclusion as follows: � Ellen�s death was caused by nitrous oxide use and immobility, which led to the development of pulmonary emboli.

Ellen Mercer attended Wexham Park Hospital, Slough in Berkshire, arriving by ambulance in the early hours of 9 February 2023. The starting point for her deterioration and hospital attendance was her mental health and her use of nitrous oxide. The cannisters she used had caused injuries to her legs and decreased her mobility. � Ellen arrived at Wexham Park Hospital at 00.48. She died there almost exactly 24 hours later, in the emergency department. No formal VTE risk assessment took place. A post mortem examination revealed that her cause of death was : 1a Bilateral Pulmonary Artery Thromboembolus 1b Deep Vein Thrombosis 2 Long term complications of nitrous oxide abuse, including immobility

I have sent a copy of my report to the Chief Coroner and to Ellen�s family. I have also sent this report to the following recipients, who have an interest in this matter: Royal College of Emergency Medicine. Royal College of Physicians. Chief Executive of Royal Berkshire Hospital NHS Trust. Legal representative for South Central Ambulance Service. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

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

13/03/2024

2024-0136

Jacob Billington

Birmingham and Solihull

G4S Birmingham and Solihull NHS Foundation Trust HMPPS Chief Constable for West Midlands Police Swansea Bay University Health Board

On 9 September 2020 I commenced an investigation into the death of Jacob Michael Nicholas BILLINGTON. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Unlawfully killed

Jacob was unlawfully killed when he was stabbed in the neck on 06/09/20 whilst on a night out in Birmingham with friends. A number of other people were also seriously injured that night by the same perpetrator over a 90 minute period. At the time of the attack the perpetrator was suffering from paranoid schizophrenia a severe and enduring mental illness which was characterised by him constantly hearing voices which at times told him to harm others including �kill em stab em�. The perpetrator had not been receiving regular prescribed anti-psychotic medication in the months leading up to attack and he also may have taken illicit drugs, both of which may have contributed to the deterioration his mental state. � On 22 April 2020 the perpetrator had been released from prison at the end of a three year sentence for drug and firearm offences. He had a long history of violent offending and was known to be a high risk of harm to the public and to have sporadic compliance with anti-psychotic medication, but there was no lawfully available control that might have been placed upon on him at the end of his sentence to protect the public from the recognised high risk he presented. � The perpetrator had a long history of refusing to engage with agencies whilst in prison. Although he had been in the community on licence under MAPPA (Multi Agency Public Protection Arrangements) he was recalled to prison on 24/12/18. Shortly after his transfer to HMP Parc on 12/9/19 the MAPPA oversight was prematurely ended without any plan in place aimed at ensuring a co-ordinated release from prison and some of the actions that were prescribed by MAPPA relating to liaison with his local CMHT were not completed. The MAPPA process did not effectively promote risk reduction as it discharged him without plans being in place for a coordinated approach to the care of the perpetrator in prison or to ensure interagency planning for his release. � The secondary mental health services In Reach team at HMP Parc failed to conduct a risk assessment or devise any care plan or risk management plan, and there was an absence of adequate coordination between all the numerous agencies involved with him in respect of resettlement and release planning. It was known by 10 March 2020 that a requested resettlement in Wrexham was not going ahead and on 3 April 2020 that he was returning to Birmingham with no fixed address. This was not communicated to the relevant agencies including the Birmingham CMHT. On release on 22 April 2020 the perpetrator requested a travel warrant to Birmingham where he lived until the events of 06 September 2020 which was also not communicated. He was released without any support in place for his serious mental illness. By the time the Birmingham CMHT identified in June 2020 where he had moved to on leaving prison he had recently changed address and establishing his whereabouts was not pursued by the CMHT until after he had presented to a new GP on 10th August 2020 asking to be prescribed anti-psychotic medication and after a new care coordinator was in place. He was then seen, on the doorstep of his home on 03 September 2020 by a CPN when he declined to attend a pre-arranged appointment with the CMHT consultant psychiatrist who already knew him from an assessment undertaken in December 2018, but he did agree to have a short telephone conversation with that psychiatrist. A limited assessment was undertaken and it was reasonably planned to instruct the GP to restart him on medication and to review him in the clinic in several weeks� time. It is not known whether he received or took any medication. Three days later the perpetrator attacked several wholly innocent members of the public in Birmingham City Centre and it was during these attacks that Jacob was killed. � The failure to adequately manage his release to Birmingham and the failure to ensure the CMHT were notified of his release resulted in a lost opportunity to assertively manage his serious mental health condition and this possibly contributed to his mental state on 06/09/20. Whilst it cannot be said that he probably would have then complied with treatment offered for his significant mental health needs there is a realistic possibility that he would have done so. � Following a post mortem/Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: � 1a SHARP FORCE NECK TRAUMA

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Jacob�s Family Midlands Partnership University NHS Foundation Trust for MHIT Shropshire Community Health NHS Trust the MHIT Forward Thinking Birmingham [REDACTED], through his solicitors � 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.

Other related deaths This report is being sent to: G4S | Birmingham and Solihull NHS Foundation Trust | HMPPS | West Midlands Police | Swansea Bay University Health Board

05/12/2023

2023-0503

Alice Litman

West Sussex, Brighton and Hove

Gender Identity Clinic NHS England Surrey and Borders NHS Partnership trust The Royal College of General Practitioners

On 01 June 2022 I commenced an investigation into the death of Alice LITMAN aged 20. The investigation concluded at the end of the inquest on 13 October 2023. The conclusion of the inquest was that: � Alice Litman, a 20 year old trans female, was found on the 26th May 2022 [REDACTED] Brighton, having died as a result of a descent from height. From her early teens it was apparent that Ms Litman had struggled with her mental health. At the age of 17, Ms Litman had made previous attempts to take her own life and was for a time under the care of the Community Adolescent Mental Health Services until she was discharged at the age of 18. At the time she was not considered to meet the threshold for adult mental health services and Ms Litman never sought further assistance from the community mental health services. At the time of her death Alice had been on the waiting list for Gender Identity Services for 1023 days which contributed to a decline in her mental health.

Alice Litman, a 20 year old trans female, was found on the 26th May 2022 [REDACTED] Brighton, having died as a result of a descent from height. From her early teens it was apparent that Ms Litman had struggled with her mental health. At the age of 17, Ms Litman had made previous attempts to take her own life and was for a time under the care of the Community Adolescent Mental Health Services until she was discharged at the age of 18. At the time she was not considered to meet the threshold for adult mental health services and Ms Litman never sought further assistance from the community mental health services. At the time of her death Alice had been on the waiting list for Gender Identity Services for 1023 days which contributed to a decline in her mental health.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Alice Litman�s family, Surrey and Borders Partnership Trust The Gender Identity Clinic WellBN Gender 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.

Suicide (from 2015) This report is being sent to: Gender Identity Clinic | NHS England | Surrey and Borders NHS Partnership Trust | The Royal College of General Practitioners

30/04/2024

2024-0230

Marlin Burrows

Liverpool and Wirral

Governing Governor HMP Garth Head of Healthcare HMP Garth

On 24th August 2022 an investigation into the death of Marlin John Burrows aged 45 was opened. The investigation concluded at the end of the inquest on 29th April 2024. The conclusion of the inquest was that the deceased died from multi-organ failure due to serotonin syndrome due to drug toxicity including amitriptyline toxicity. The jury found that the deceased had died as a result of an accident, a failure to consult Tox Base and failing to identify that the deceased was prescribed amitriptyline, contributing to his death.

Marlin Burrows was found on 15th August 2022 collapsed in his cell at HMP Garth. Prison and Healthcare staff assumed that he was intoxicated through Psychoactive substances. A quantity of prescribed medication was found in the cell including amitriptyline. Healthcare staff failed to recognise that the drugs were not prescribed for the deceased and failed to consult Tox Base in order to determine the toxicity of amitriptyline if taken in excess. A Welfare Log was opened by prison staff but only completed intermittently and not consulted by medical staff. In the early hours of 16th August 2022 having been in a semi-conscious state for nearly 15 hours the deceased collapsed and died.

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

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

20/12/2022

2022-0407

Alexander Braund

Nottingham City and Nottinghamshire

Governing Governor, HMP Nottingham � ������������������������������� Executive Medical Director and Executive Director of Forensic Services, Nottinghamshire Healthcare NHS Foundation Trust Founder and CEO, TPP-UK

On 06 April 2020, I commenced an investigation into the death of Alexander Michael BRAUND, aged 25.� The investigation concluded at the end of an inquest, conducted before a Jury, on 30 November 2022. � Alex was a remand prisoner at HMP Nottingham, when he became acutely unwell on 6 March 2020, with symptoms of a productive cough (brown sputum) and feeling generally unwell. � He deteriorated such that by the 8 March 2020 he was coughing, vomiting, wheezing, wasn�t eating and had a headache. � Alex and/or his cell mate pressed the emergency buzzer inside their cell at 22.22 hours on 9 March 2020 because Alex had deteriorated further. He had a burning sensation in his chest and difficulty breathing. The nurse attended but did not perform a complete NEWS2 assessment, take a sputum sample, nor listen to his chest. A plan was made to refer Alex to the prison GP the next day. � There was no agreed plan between healthcare and discipline staff as to whether or how frequently Alex ought to be checked in his cell, what constituted a deterioration of his condition, and what to do in such circumstances. � At 05.35 hours on 10 March 2020 the emergency cell bell was activated again. Alex�s cell mate explained to the PCO that he was increasingly concerned about Alex�s condition and that he wanted to see healthcare. Sometime later the nurse attended the wing but did not see Alex. She told the PCO nothing more could be done at this time of night. � Alex was noted to be collapsed on the floor of his cell at 06.55 hours, and his cell mate raised the alarm by pressing the emergency cell bell for the third time. The PCO in charge of the wing failed to clearly establish whether Alex was breathing. There was a delay in entering his cell for the provision of basic life support, and there was a delay in calling a code blue, which in turn delayed the dispatch of an ambulance. These delays probably more than minimally contributed to Alex�s death. Alex was declared deceased at 11.44 hours on 10 March 2020 in the Intensive Care Unit at Queens Medical Centre, Nottingham, following the withdrawal of life support. He had been suffering from an atypical pneumonitis that was not detected. � The continuous failures to provide adequate healthcare to Alex probably more than minimally contributed to his death.

The conclusion of the Jury was that Alex died on 10 March 2020 as a result of a hypoxic- ischaemic brain injury, caused by cardiac arrest with prolonged downtime, caused by an atypical pneumonitis, to which neglect had probably contributed.

I have sent a copy of my report to the Chief Coroner and to the Interested Persons. I have also sent it to ������� Ministry of Justice, Minister for Prisons, Parole and Probation, The Rt. Hon. Damian Hinds ������� Care Quality Commission ������� Independent Monitoring Board, HMP Nottingham ������� Prison and Probation Ombudsman � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.

State Custody related deaths

HMP Nottingham, Forensic Services Nottinghamshire Healthcare NHS Foundation Trust and TTP-UK

17/10/2023

2023-0389

Terence Davenport

Manchester South

Greater Manchester Integrated Care

On 29th September 2022 I commenced an investigation into the death of Terence Davenport. The investigation concluded on the 23rd August 2023 and the conclusion was one of Narrative: Died from the complications of being pushed over by another resident at the care home where he resided when the risk presented by the other resident was not fully understood contributed to by his dementia and ischaemic heart disease. The medical cause of death was 1a) Pneumonia on the background of the fractured left neck of femur (operated); II) Dementia (mixed type), ischaemic heart disease

Terence Davenport had dementia and lacked capacity. He was looked after at home by his wife. Following his admission to hospital he had to be placed urgently in a nursing home, as he was not safe to remain at home. A place was found for him at Kings Park Nursing Home. On 23rd May 2022 he was pushed by another resident who lacked capacity due to dementia. He fell as a consequence of the push and was admitted to the hospital where a fracture to the neck of femur was found. The other resident had a history of aggressive behaviour to others not known to the manager of Kings Park. On the balance of probabilities had that history been known the home would not have accepted that resident. Mr Davenport was operated on. Post-operatively he did not regain mobility and he declined nutritionally. This was probably as a consequence of the impact of the fall, fracture and operation on his cognition. He remained in an acute hospital setting after he was medically fit for discharge as a suitable care placement needed to be found for him. He continued to decline in the acute setting which was a difficult setting for him given his severe dementia. He was moved on to end of life care whilst awaiting discharge. He died at Tameside General Hospital on 24th September 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) [REDACTED] on behalf of the Family; 2) Tameside Metropolitan Borough Council; 3) Kings Park Nursing Home; 4) Tameside General Hospital, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Care Home Health related deaths This report is being sent to: Greater Manchester Integrated Care

19/07/2023

2023-0259

Michael Amesbury Coroner name: Alison Mutch Coroner Area: Manchester South Category: Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Greater Manchester Integrated Care

Greater Manchester Integrated Care

On 6th December 2022 I commenced an investigation into the death of Michael Kevin Amesbury. The investigation concluded on the 25th May 2023 and the conclusion was one of Narrative: Died from a combination of bronchopneumonia (not diagnosed until after death) and aspiration of gastric contents exacerbated by heart failure for which he was awaiting assessment regarding his suitability for surgical intervention. The medical cause of death was 1a) Bilateral Bronchopneumonia and aspiration of gastric contents; II) Heart Failure, Diabetes Mellitus, Dapagliflozin therapy

Michael Kevin Amesbury had an extensive cardiac history. He was becoming increasingly unwell as a consequence. On 24th October 2022 he had a trans-oesophageal echocardiogram that confirmed he had severe mitral regurgitation. He was referred to Wythenshawe Hospital for surgical assessment. Whilst awaiting assessment he became increasingly unwell. He was prescribed Dapagliflozin medication which led to a rapid rise in his ketones and he became increasingly unwell. He was admitted to Tameside General Hospital on 30th November 2022 .Whilst an in-patient at Tameside General Hospital he became unresponsive. Cardiopulmonary resuscitation was undertaken during which there was severe vomiting of gastric contents. He died at Tameside General Hospital on 30th November 2022. Post-mortem examination confirmed he had died from bilateral bronchopneumonia (not diagnosed in life) in combination with extensive aspiration of gastric contents. He had extensive evidence of heart failure which on the balance of

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

20/07/2023

2023-0261

Elliott Harratt

Manchester South

Greater Manchester Integrated Care

On 1st February 2023 I commenced an investigation into the death of Elliott James Harratt. The investigation concluded on the 26th June 2023 and the conclusion was one of Natural causes. The medical cause of death was 1a Extreme Prematurity

Elliott James Harratt�s mother went into early labour with him. He was born at the family home and transferred to Tameside General Hospital. He was 20 plus 4 weeks gestation. He died at Tameside General Hospital on 29th January 2023 from extreme prematurity

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

Child Death (from 2015) This report is being sent to: Greater Manchester Integrated Care

13/03/2024

2024-0140

Alan Smith

Manchester South

Greater Manchester Integrated Care

On 25th September 2023 I commenced an investigation into the death of Alan William Rowland Smith. The investigation concluded on the 8th February 2024 and the conclusion was one of narrative: Died from the complications of chronic venous insufficiency when the severity of his condition was not recognised at an early stage and there was not an early referral to vascular services. The medical cause of death was 1a) Frailty 1b) Infected Leg 1c) Chronic Venous Insufficiency on a background of past thrombotic syndrome

Alan William Rowland Smith developed severe leg swelling as a consequence of venous insufficiency following a probable venous thrombosis. He developed an infected leg and he deteriorated rapidly. He died at Stepping Hill Hospital on 17th September 2023. The severity and risk posed by the swelling was not recognised at an early stage and as a consequence early interventions to reduce swelling and reduce the risk of deterioration and death did not take place.

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

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

29/01/2024

2024-0042

Terence Briney

Manchester South

Greater Manchester Integrated Care

On 21st March 2023 I commenced an investigation into the death of Terence Briney. The investigation concluded on the 8th December 2023 and the conclusion was one of Natural Causes. The medical cause of death was 1a) Acute respiratory event on the background of an aspiration 1b) Frailty II) Myocardial Infarction, Ischaemic Heart disease and Aortic Stenosis

Terence Briney�s health began to deteriorate significantly from July 2022. His appetite reduced, he had increasing lethargy and developed tremors. He began to lose weight. No investigations were carried out until he was referred to gastroenterology on the cancer pathway. He was very frail by the time of the referral. The tests indicated his oesophagus was not functioning effectively but there was no clear cause. He was admitted to Stepping Hill Hospital on 15th March 2023 after the GP examined him and was concerned about how frail he was. On admission no clear reversible cause was identified. He was put on Nil by Mouth due to his poor oesophageal functionality. He presented a high risk of aspiration. On the balance of probabilities, the deterioration in his oesophageal function was due to an undiagnosed neurological condition. On 17th March he suffered an acute respiratory event due to aspirating on his saliva. He died at Stepping Hill Hospital on 17th March as a consequence.

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: Greater Manchester Integrated Care

11/09/2024

2024-0491

Nisren Abdul-Karim

South Manchester

Greater Manchester Integrated Care

On 5th August 2024 I commenced an investigation into the death of Nisren� ABDUL-KARIM. The investigation concluded on the 19th August 2024 and the� conclusion was one of Narrative: Died from natural causes contributed to by� the complications of an accidental fall sustained whilst unobserved as an� inpatient. The medical cause of death was 1a) Hospital acquired pneumonia 1b) Frailty 1c) End stage neurodegenerative condition II) Fall (1st Nov)� requiring surgery for hip fracture (2nd Nov), Behcet�s disease.

Nisren Abdul-Karim had a number of underlying health conditions including� Behcet�s disease. In Autumn 2023 she began to hallucinate. She was admitted� again to Wythenshawe Hospital on 21st October 2023. She was a high falls risk. Whilst an inpatient and unobserved she had a fall. She should not have been� unobserved. She was operated on for a fractured hip sustained in the fall. She� was transferred to Trafford General Hospital for rehabilitation on 10th� November. The transfer meant that access to neurology was more difficult� because the service provided by neurologists was not available at Trafford� General Hospital. She continued to deteriorate at Trafford General Hospital.� Further advice was sought via patient pass from the neurology team at Salford� Royal Hospital. Review of the scans previously undertaken concluded that she� had irreversible neurodegenerative disease. She continued to deteriorate and� died at Trafford General Hospital on 5th January 2024.

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

Hospital Death (Clinical Procedures and medical management) related deaths

Greater Manchester Integrated Care

02/07/2024

2024-0352

James Cockburn

Manchester South

Greater Manchester Integrated Care Board NHS England

On 30th May 2023 I commenced an investigation into the death of James Neil COCKBURN. The investigation concluded on the 29th May 2024 and the conclusion was one of Narrative: Died from a myocardial infarction whilst under the care of cardiac specialist teams for assessment for cardiac intervention. The medical cause of death was 1a) Acute myocardial infarction 1b) Coronary artery atheroma 1c) II Diabetes (type 2), Aortic Stenosis, End stage renal disease (on Dialysis), Hypertension, Obesity

James Neil Cockburn had multiple comorbidities. He was referred in August 2022 to cardiology after an echocardiogram indicated he had moderate to severe aortic stenosis of the aortic valve. He had a cardiology appointment on 12th December 2022 and was referred for a trans oesophageal echocardiogram in February 2023. A further echocardiogram on 23rd February at Salford Royal Hospital confirmed severe aortic stenosis that result was entered on the Manchester University Foundation Trust system on 17th March 2023. He was referred to the cardiac surgery team. He saw the cardiac surgeon on 10th May 2023. He was referred for further tests to assess for open heart surgery. Whilst awaiting these tests he had a myocardial infarction and died at his home address on 26th May 2023.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely [REDACTED] on behalf of the family and 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: Greater Manchester Integrated Care | NHS England

10/02/2023

2023-0051

Sandra Lomax

Manchester South

Greater Manchester Integrated Care and NHS England

On 30th June 2022 I commenced an investigation into the death of Sandra Adina Lomax. The investigation concluded on the 4th January 2023 and the conclusion was one of Narrative: Died from The complications of an oesophageal stent, required for the recognised consequences of chemo/radiotherapy, where the stent was not removed within the recognised timescales. The medical cause of death was 1a) Bronchopneumonia; 1b) Oesophageal Granulation on the background of a Stent; 1c) Oesophageal Cancer (treated with chemo/radiotherapy)

Sandra Adina Lomax was diagnosed with oesophageal cancer in 2021. She was successfully treated with chemo/radiotherapy. She was referred to Tameside General Hospital for a post treatment endoscopy. In December 2021 an endoscopy identified a tight pinhole stricture. A stent was inserted as it was suspected that there was a perforation. The type of stent inserted required removal within 6 weeks in a case such as Mrs Lomax�s. � A combination of factors including clinicians not communicating effectively and no ownership of Mrs Lomax�s case meant that the stent was not removed within 6 weeks. An attempt to remove the stent on 22nd March was unsuccessful because the stent was embedded due to the time that had elapsed since it was inserted. � This was not urgently escalated although it was recognised this was a complex situation with potentially significant consequences for Mrs Lomax. She was scheduled to begin a complex stent removal process on 22nd June 2022. An operation at Salford Royal Hospital did not take place because the preoperative procedure was not followed. She had a series of bleeds in June 2022 that culminated with her being admitted to Stepping Hill Hospital on 19th June 2022. Her haemoglobin level was low. She developed pneumonia from the complications of the oesophageal granulation of the stent. She was treated with antibiotics but continued to deteriorate. She died at Stepping Hill Hospital on 25th June 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) Mr Lomax on behalf of the Family; 2) Salford Royal Hospital; 3) Stepping Hill Hospital; 4) Tameside General Hospital; 5) The Christie 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

Greater Manchester Integrated Care and NHS England

23/04/2024

2024-0216

Ashley Crews

Manchester City

Greater Manchester Police Chief Coroner [REDACTED]College of Policing IOPC -Independent Office for Police Conduct

INQUEST � The Inquest was opened on 12th March 2024. The final hearing has not yet taken place. Following disclosure of evidence from Greater Manchester Police (�GMP�) and the Independent Office for Police Conduct (�IOPC�), there is concern that future deaths will occur, and I am of the opinion that action should be taken to reduce the risk of death.

Mr Ashley Crews died on 20th February 2024 from injuries sustained from a fall from height. On 20th February 2024, GMP officers attended Mr Crews� address (a 9th floor flat) to execute an arrest warrant. The attending officers did not apply handcuffs. Mr Crews proceeded to walk to his bedroom in the flat, and whilst some officers followed him, Mr Crews was able to open a window and jump out. GMP have confirmed that they do not have a local policy dealing with the use and application of handcuffs when executing an arrest warrant. The IOPC have confirmed there is no national policy.

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

Other related deaths This report is being sent to: Greater Manchester Police | College of Policing | Independent Office for Police Conduct

19/02/2024

2024-0089

Samuel Curless

Manchester South

Greater Manchester Police The College of Policing

On the 25th October 2022, I commenced an investigation into the death of Samuel Curless (Sam). Sam died on the 24th October 2022 at the Manchester Royal Infirmary. He was 29 years old. The investigation into his death concluded on the 2nd February 2024 when I completed the inquest into his death. The medical cause of death was found to be 1a) Hypoxic Ischaemic Encephalopathy caused by 1b) hanging. � I recorded a conclusion of suicide.

Sam had a long history of anxiety and depression. He had reported feeling suicidal in the past. He was the sole carer for his young son and his son was a protective factor for him. � On the 23rd September 2022, the deceased was arrested at home in relation to an allegation of a serious criminal offence. He was taken to the police station where he was interviewed under caution. He was released on bail the same day with conditions not to have any contact with anyone under the age of 18. On Friday 21st October, Sam was informed that all of his bail conditions were removed, but that he remained under investigation. He was provided with police documentation that confirmed this. Sam contacted the children�s social worker and informed her of the change to his bail and asked if he could now see his son unsupervised. The social worker told him that she would need to verify the bail position with the police before their plan could change. Sam agreed to continue with the supervised contact on Monday, but he would have found it difficult to hear and understand. � At 14:05 on Saturday 22nd October, Sam made a call to GMP 101 service from his mobile phone. This call was connected to a GMP Call Handler at 14:12 and a police log was commenced. From the audio recording of the call, Sam could be heard telling the Call Handler that he thought he had found a dead body. He gave the location [REDACTED]. He said it was the first plot near some stainless-steel containers near the car park. The conversation between the deceased and the call handler lasted approximately 40 seconds, after which Sam did not respond to further attempts at engagement. The call handler kept the line open for just over 5 minutes. � As the deceased�s call to GMP was a 101 call (and not a 999 call), the Call Handler was not able to obtain the precise location using his mobile phone and data services. She obtained a street name to add to the location after talking to her supervisor. The Call Handler did not know that the deceased had any intent to take his own life, but she did conclude that there was a risk that the dead body he was reporting might not be dead. At 14:29 she graded the THRIVE risk as High and Graded the GMP Response as 1. She coded the call as G15 which includes a concern for welfare or risk of suicide. Radio Operators dispatched GMP officers at 14:33. � The Call Handler failed to call an ambulance at 14:29. It was a GMP minimum standard expectation that she should have done so at the point that she had a location to dispatch to and was part of her training in response to reports of a dead body. [REDACTED] gave evidence to the inquest that this was an admitted failing by GMP, but I found that it did not make any material contribution to the death. � Two Officers attended [REDACTED] at 14:38 within the Grade 1 response time. They located the Sam in a shed [REDACTED] at 14:42. They found him suspended from a ligature [REDACTED]. � The first officer on the scene assumed that she was looking at a dead body. She did not check for a pulse until around 14:46. A total of three officers were in attendance by this point. A further check at 14:48 revealed that he was still warm and only at that point was he cut down. After further checks for a pulse, CPR was commenced by the officers at 14:50. � The three initial attending officers failed to administer any basic life support to Sam for approximately 8 minutes after discovering him suspended. The officers failed to perform any immediate initial checks of Sam�s vital signs when they discovered him. The officers failed to remove the ligature and therefore an airway obstruction at the earliest opportunity. � It was GMP and College of Policing Policy that officers attending a suspected sudden death should not assume death, should make preservation of life their priority and not delay in administering basic life support until an ambulance arrives. In their evidence to the inquest, these failings were admitted by the officers but I found that did not make any material contribution to the death. � The attending officers all assumed that an ambulance had been called by GMP comms. In fact, one was only contacted at 14:48. NWAS went mobile at 14:57 and attended the scene at 15:01 and commenced advanced life support. Following paramedic intervention, spontaneous circulation returned at 15:24. � Sam was then taken to Manchester Royal Infirmary, where despite appropriate resuscitation and life preserving treatments he died on the 24th October 2022.

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) Sam�s Family; 2) Independent Office of Police Conduct (IOPC); 3) Tameside Metropolitan Borough Council, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

Suicide (from 2015) This report is being sent to: Greater Manchester Police | The College of Policing

08/12/2023

2023-0513

Claire Briggs

Manchester South

Greater Manchester Police � Chief ConstableCheshire Constabulary � Assistant Chief Constable Cumbria Constabulary � Chief Constable Lancashire Constabulary � Assistant Chief Constable Merseyside Police � Chief Superintendent (RR Command) British Transport Police � FCR Operations Manager North West Ambulance Service � Chief Executive North West Fire Control � Senior Operations Manager Lancashire Fire and Rescue Service � Group Manager Merseyside Fire and Rescue Service � Station Manager Greater Manchester Integrated Care Board � Chief Nursing Officer Lancashire and South Cumbria Integrated Care Board � Chief Nurse Cheshire and Merseyside Integrated Care Board � Chief Nurse

On 29th November 2022 an investigation was commenced into the death of Claire Nicole Briggs, aged 42 years. The investigation concluded at the end of the inquest on 12th July 2023. The conclusion of the inquest was that she died of a propranolol overdose on 28th November 2022 at Stepping Hill Hospital, Stockport, having taken approximately [REDACTED] propranolol tablets from previous prescriptions. She declined to be taken to hospital by the police for the critical time period after she had taken the tablets. There were 2 admitted failings by the North West Ambulance Service effectively to conduct clinical reviews of the incident which were not in themselves causative of her death, but the combined effect of those failings, the absence of any method within the NHS Pathways system to identify high risk overdoses and the pressures on the deployment of ambulances on that day combined to lead to a delay in her arrival at hospital which possibly contributed to her death.

Claire Briggs was first prescribed propranolol from 2008 and had been regularly prescribed daily doses of that medication since 2019. [REDACTED] . I found, on the evidence, that she had consumed approximately [REDACTED] propranolol tablets. � A friend and the police attended at her home quickly. Ms Briggs was resistant to be taken to hospital until the time at which the effects of the ingestion of drugs became evident. Notwithstanding her stance, the police officers and others at the scene made repeated calls to the ambulance service. In total, 9 calls were made between 4.37pm and 6.12pm, 6 of which were made prior to Ms Briggs relenting and accepting that she should be taken to hospital and a further separate call by the police to the Hear and Treat helpline. The evidence I heard was that calls made by police officers from the scene to NWAS are triaged in the same way as other 999 calls. � The ambulance service call handlers used the NHS Pathway process in dealing with each of the calls, which prompted a response category under the NHS Pathway system which resulted in a Category 3 response, which was not upgraded to Category 2 until a call made at 17.53 and the incident was prioritised at 18.16 so that the next available ambulance was allocated to respond. � There were significant delays within the ambulance service at that time, such that national target response times were significantly breached. � Prior to the arrival of the ambulance and in light of Ms Brigg�s obviously deteriorating condition and the uncertainty over the arrival time of the ambulance, the police officers decided to transport her to hospital themselves by police vehicle, but she experienced seizures before the police car left the vicinity of her address, which as closely followed by the arrival of the ambulance at 18.32. The police officers at the scene, in the calls they made from the scene and through their control room were unable to convey the seriousness of Ms Brigg�s condition to the ambulance service. � She went into cardiac arrest at the scene in the back of the ambulance and was subsequently taken to hospital, where, despite care and treatment under guidance from a senior member of the National Poisons Advice Service, she died. � The ambulance service accepted that there were failures to undertake timely clinical reviews of the incident.

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

Emergency services related deaths (2019 onwards) | Alcohol, drugs medication related deaths This report is being sent to: Greater Manchester Police | Cheshire Constabulary | Cumbria Constabulary | Lancashire Constabulary | Merseyside Police | British Transport Police | North West Ambulance Service | North West Fire Control | Lancashire Fire and Rescue Service | Merseyside Fire and Rescue Service | Greater Manchester Integrated Care Board | Lancashire and South Cumbria Integrated Care Board | Cheshire and Merseyside Integrated Care Board

03/07/2024

2024-0357

Andrew Story

Cheshire

Greek authorities via FCDO

On 05 January 2024 I commenced an investigation into the death of Andrew James STORY aged 56. The investigation concluded at the end of the inquest on 26 June 2024. The conclusion of the inquest was that: � Accident

On 12 October 2023, 56 year old Andrew Story went for a swim in the sea in Rethymno whilst on holiday in Crete. He was only gone for a few minutes when a bystander was seen undertaking CPR on him, on the beach. A post mortem conducted in Greece offered a cause of death as drowning in sea water. A UK post mortem identified drowning but also left ventricular hypertrophy. Mr Story was taken away by ambulance but was sadly confirmed deceased thereafter.

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.

Other related deaths This report is being sent to: Foreign, Commonwealth and Development Office