Inquests (PFDs)

Date	Reference	Deceased	Coroner Area	Sent to	Investigation	Circumstances	Sent to	Categories	Also sent to
10/05/2024	2024-0495	Terence Manning	Blackpool & Fylde	HADDON COURT REST HOME, BLACKPOOL	On 9 and 10 May 2024, at an inquest held at Blackpool Town Hall, I returned a short form conclusion that Mr Terence Manning died as a result of an accident.�� I found the cause of death to be: 1(a) Hypoxic brain injury 1(b) Out of hospital cardiac arrest 1(c) Choking on a food bolus II Frontotemporal dementia	I returned the following in box 3 of the Record of Inquest recorded: Mr Terence John Manning resided at Haddon Court Rest Home, 8-14 Haddon Road, Blackpool. Mr Manning had become a resident at Haddon Court on 29 June 2023. On 22 October 2023, Mr Manning was eating a meal at the rest home, when he experienced a choking incident. Mr Manning was taken by ambulance to Blackpool Victoria Hospital where, despite receiving treatment he died on 24 October 2023. Mr Manning had been identified to have a propensity to eat quickly, but a Speech and Language Therapy (�SALT�) referral had not been made in his case, in circumstances where there was an opportunity for such a referral to have been made. It is not possible to say as to what the conclusion of any SALT referral would have been.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� The family of Terence Manning The Care Quality Commission Lancashire County Council 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.	Care Home Health related deaths	HADDON COURT REST HOME, BLACKPOOL
14/07/2023	2023-0243	Terence Burns	Blackpool & Fylde	HIGHGROVE REST HOME, BLACKPOOL	On 10 July 2023, at an inquest held at Blackpool Town Hall, I returned a short form conclusion that Mr Terence Burns died as a result of misadventure. � � I found the cause of death to be: 1 (a) Choking ii Bronchopneumonia and brain infarct	I returned the following in box 3 of the Record of Inquest recorded: � Mr Terence Burns was resident at the Highgrove Rest Home, Blackpool. The care plan that was put in place for Mr Burns included that he required a blended food diet. On 28 October 2022, Mr Burns� physical condition deteriorated and an ambulance was called to the Highgrove Rest Home. When Mr Burns was transferred to Blackpool Victoria Hospital, his dietary requirements were not notified to North West Ambulance Services. Consequently, during his course of treatment, the dietary requirements for Mr Burns were not known by Blackpool Victoria Hospital. During the evening of 28 October 2022, Mr Burns was given a sandwich to eat at Blackpool Victoria Hospital. At approximately 22.52hrs on 28 October 2022, Mr Burns was found unresponsive in the hospital cubicle with food reside in his throat. Mr Burns displayed no breathing effort and died at approximately 23.00hrs.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � The family of Terence Burns The 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.	Care Home Health related deaths This report is being sent to: Highgrove Rest Home
21/08/2023	2023-0304	Jacqueline Smith	West London	HILLINGDON COUNCIL Forward Trust Central and North West London Mental Health Trust	On 16 August 2022 I commenced an investigation into the death of Jacqueline Elizabeth SMITH. The investigation concluded at the end of the inquest . The conclusion of the inquest was suicide Cause of death � 1a Respiratory depression 1b [REDACTED] overdose, [REDACTED]	Took her own life by an overdose of prescribed medication at home and died in Hillingdon Hospital on 12 August 2022. At the time she was in poor physical health and experiencing considerable anxiety as she was trying, with assistance from the Council, to clear her home of numerous hoarded possessions. She spoke with the single point of access (SPA) crisis telephone service during the evening of 10th August to ask for help, but no mental health assessment was performed and she was not called back by the team as promised. Her neighbour requested a welfare check be performed the next day when she was found collapsed and taken to hospital.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Family, Forward Trust, Central and North West London Mental Health Trust I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) \| Mental Health related deaths \| Alcohol, drugs medication related deaths This report is being sent to: Hillingdon Council \| Forward Trust \| Central and North West London Mental Health Trust
14/07/2023	2023-0250	Sean Heeney	Northamptonshire	HIS MAJESTY�S PRISON AND PROBATION SERVICE	On 2nd October 2019 an investigation was commenced into the death of Sean Anthony Heeney, aged 34. The investigation concluded at the end of the inquest on 13th July 2023. The conclusion of the inquest was a narrative conclusion: Sean Heeney was found unconscious at Bridgewood House on 22nd September 2019 and passed away on 26th September 2019 at Northampton General Hospital. The initial call to 999 on 22nd September was incorrectly categorised, an admitted failure on EMAS� behalf, which made a material contribution to his death. Ambulance staff that attended did not properly appreciate the seriousness and urgency of Sean Heeney�s condition and, as such, it was not escalated appropriately. The lack of proper monitoring by the ambulance staff made a contribution to his death. This was a drug-related death. The medical cause of death was: 1a Hypoxic brain injury 1b Cardiac arrest 1c Aspiration pneumonia 1d Use of heroin and cocaine	At the time of his death, Mr Heeney was a resident at Bridgewood House Approved Premises in Northampton. He had been released from prison on licence on 9th September 2019. Mr Heeney had a history of drug and alcohol misuse. At or around 06.00 on 22nd September Mr Heeney was found unresponsive on the floor of his first-floor bedroom. Shortly thereafter the residential worker who discovered Mr Heeney called 999. At 06.35 a technician-led ambulance crew arrived at Bridgewood House. Mr Heeney was found to have a Glasgow Coma Scale (�GCS�) of 4 and with oxygen saturation levels of 28%. At 06.44 an ambulance technician called for paramedic assistance. At 06.51 a paramedic-led ambulance crew arrived at Bridgewood House. At 07.25 the East Midlands Ambulance Service (�EMAS�) requested assistance from Northamptonshire Police in order to extricate Mr Heeney from his bedroom. At 07.36 two police officers arrived at Bridgewood House. They themselves requested additional support, with further officers arriving at 07.47. At or around 07.52 Mr Heeney was handcuffed to the rear by the police officers. They lifted Mr Heeney to his feet which caused postural hypotension which led to cardiac arrest. Advanced life support was commenced. A doctor attended and was able to intubate Mr Heeney with an endotracheal tube at or around 08.25. A return of spontaneous circulation was achieved at 08.36. Mr Heeney was eventually removed from his bedroom by means of a scoop stretcher. At 08.59 he departed from Bridgewood House to Northampton General Hospital. By the time that Mr Heeney arrived at Northampton General Hospital he was very unwell: his breathing was being managed by a ventilator. His oxygen saturations and blood pressure were very low. He was unconscious with a GCS of 3. Arterial blood gas measurements suggested a prolonged period of cardiac arrest. On 26th September 2019 Mr Heeney died.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1.�� Sean Heeney�s family. 2.�� East Midlands Ambulance Service. 3.�� Chief Constable of Northamptonshire Police. 4.�� Independent Office for Police Conduct. I have also sent it to the Prisons and Probation Ombudsman and the Northamptonshire Fire and Rescue Service who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	State Custody related deaths \| Alcohol, drugs medication related deaths	HM Prison and Probation Service
23/06/2023	2023-0210	Stephen Beadman	West Yorkshire (Eastern)	HM Prison Wakefield, [REDACTED] , Governor Ministry of Justice � Rt Hon Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE	On 20th April 2021 I commenced an investigation into the death of Stephen Kurt Beadman, aged 34. The investigation concluded at the end of the Inquest on 21st June 2023. The conclusion of the Inquest was a Narrative which included a finding that Mr Beadman committed suicide having been bullied by other prisoners.	Mr Beadman, aged 34, was serving a long sentence at HMP Wakefield. � He had repeatedly complained of being bullied and was in fear that a �contract� was out on him following suspicions that he was an informer. He had a long history of self- harming. � On 7th April 2021 around 2:30pm he barricaded himself in his cell and inflicted wounds [REDACTED] issued to him by the prison which he was entitled to have in his possession in his locked cell. An ACCT was opened that afternoon as he was in an agitated state. He was seen at 4pm and 4:30pm but at 5:05pm he was found in an unresponsive state with a neck ligature applied to his neck. He died in hospital the following day, 8th April 2021. Mr Beadman, aged 34, was a serving prisoner at HMP Wakefield. He had been diagnosed with a mixed personality disorder along with mixed depression and anxiety. He was prescribed medication. He had a long history of self-harm and in 2020-21 repeated suicide attempts. On 7th April 2021 he was found in an unresponsive state having applied a ligature to his neck. He died the following day, 8th April 2021 in hospital from: 1(a) Hypoxic Ischaemic Encephalopathy 1(b) Cardiac Arrest 1(c) Hanging	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1)��[REDACTED] , Mother of Stephen K Beadman 2)�� Practice Plus Group, [REDACTED] 3)�� Midlands Partnership University NHS Foundation Trust, [REDACTED] I have also sent it to:� 1)��[REDACTED] , Governor, HMP Wakefield 2)��[REDACTED] , Government Legal Department who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	State Custody related deaths \| Suicide (from 2015)\| Mental Health related deaths This report is being sent to: HM Prison Wakefield \| Ministry of Justice \| NHS England
25/11/2024	2024-0667	Jonathon Lawlor	Mid Kent and Medway	HM Prison and Probation Service	On 27 October 2023 I commenced an investigation into the death of Jonathon Paul LAWLOR. The investigation concluded at the end of the inquest . The conclusion of the inquest was� The deceased died as a result of an accident.� 1a Acute Multi-Organ Failure With Pulmonary Congestion and Oedema 1b Cocaine Toxicity 1c 1d II	The deceased was held on remand at HMP ELMLEY where he had been since 24/06/2023. He was resident in a single cell in house block 4 having spent some time in the inpatient� department. There was evidence heard that he had previously used drugs but not in the�prison environment itself and he was never observed by staff to be under the influence of� substances. On the morning of 19th October 2023, he was seen a number of times but did not� leave his cell as he complained of a headache, he did not wish to attend healthcare. At 11:29� hours a prison officer attended his cell to begin lunch procedures when he discovered the� deceased laying face down on the floor of his cell unresponsive. The deceased had a small� superficial injury to his head on the right side, and his head and shoulders were beneath his� metal framed bed, with his body laying diagonal across the room coming out from the bed. The officer immediately declared an emergency and commenced CPR. Other officers attended to� assist, and at 11:40 prison Doctor arrived and commenced treatment, this included use of a� Defibrillator which found no shockable rhythm. At 11:47 hours the Doctor declared life extinct,� and a post mortem revealed he had died as a consequence of Cocaine toxicity.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons� his family, HMP Elmley and Oxleas 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.	State Custody related deaths \| Alcohol, drug and medication related deaths	HM Prison and Probation Service
16/01/2024	2024-0025	Trevor Monerville	East Sussex	HM Prison and Probation Service Practice Plus Group	On 22 April 2021 I commenced an investigation into the death of Trevor Alan MONERVILLE aged 33. � The investigation concluded at the end of the inquest on 25 September 2023. � The conclusion of the inquest was a narrative verdict finding that Trevor Alan Monerville died as a result of natural causes, namely SUDEP having suffered from epilepsy and non epileptic attack disorder. He was detained at HMP Lewes initially on the healthcare wing, and then on M wing in a single cell. Monitoring ceased once the ACCT was closed on 10.03.21. � On 18.04.21 in the morning Trevor was found unresponsive in his cell and death was confirmed soon after. The communications between all organisations within the prison and between the prison and outside agencies, the monitoring systems, the sharing of medical information and engagement with Trevor�s family were found to be inadequate and there was insufficient and inadequate management of Trevor�s care.	Trevor Monerville had been detained at HMP Lewes since 30.11.20. He was moved to M wing on 16.01.21.He was placed in a single cell and appeared settled and was part of the daily cleaning crew. � He was last seen by the night staff at around 0500hrs on 18.04.21 during routine checks. � At 0950hrs he was found unresponsive face down in his cell floor. Prison staff rolled him onto his back and saw blood around his nose. CPR was started and am ambulance called. The ambulance crew continued CPR in spite of obvious signs of rigor mortis in his lower limbs for approximately 1 hour. ROLE was confirmed at 1059hrs. A brief search of the cell revealed a significant quantity of medication in tablet form some of which was no longer coated and stuck together indicating it had been removed from the mouth. � The cause of death found at post mortem examination was 1a Sudden Unexpected Death in Epilepsy.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Family of Trevor Monerville I have also sent it to: Prisons and Probation Ombudsman Independent Advisory Panel on Deaths in Custody HM Inspectorate of Prisons who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	State Custody related deaths This report is being sent to: HM Prison and Probation Service \| Practice Plus Group
05/02/2024	2024-0055	Liam Turner	Manchester City	HM Prison and Probation Service � Copied for interest to: Chief Coroner Foster Parents of the Deceased HMP Manchester Ministry of Justice Greater Manchester Mental Health NHS Foundation Trust Delphi Medical	INQUEST � A jury concluded the inquest into the death of Liam Turner on 31st January 2024 and recorded that he died from: � 1a Toxicity of ADB-BUTINACA (�[REDACTED]/ novel psychoactive substance) in [REDACTED] The jury returned a conclusion of Drug related death.	The Deceased died at HMP Manchester on 6th December 2021. His death was caused by a mixed toxicity of a psychoactive substance and prescription medication. There were admitted failings made by the Ministry of Justice (on behalf of HMP Manchester) relating to the fact that a prison officer should have raised concerns that the Deceased was under the influence of an illicit substance with healthcare earlier than he did; however, these failings did not contribute to the Deceased�s death. � When three officers found the Deceased unresponsive in his cell, they moved him from his bed to the floor in preparation to commence cardiopulmonary resuscitation (CPR); however, CPR was not commenced until the healthcare nurses (and subsequently paramedic) arrived. � I sought evidence about training for CPR, and I was informed by one witness that he received training in 2006 as part of his Emergency First Aid at Work (EFAW) training; however, he had never had any refresher training. � The training certification expires after 3 years, and it is not mandatory for prison officers to receive refresher or additional training.	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.	Alcohol, drug and medication related deaths This report is being sent to: HM Prison and Probation Service
04/12/2024	2024-0672	Kayleigh Melhuish	Avon	HMP Eastwood Park Healthcare � Practice Plus Group Mental Healthcare � Avon and Wiltshire Mental Health Partnership Trust Ministry of Justice	On 19th July 2022 I commenced an investigation into the death of Kayleigh Ann MELHUISH. The investigation concluded at the end of the inquest on 17th October 2024. The conclusion of the inquest was Suspension by a ligature contributed to by neglect.	Kay arrived at HMP Eastwood Park on 15th June 2022. It was her first time in prison and she had a history of autism, attention deficit and hyperactivity disorder (ADHD), and a personality disorder. She arrived with a suicide and self-harm warning form having been completed as she had tried to [REDACTED]. Staff started a suicide and self-harm monitoring process referred to as an ACCT. Initially Kay was placed on the prison induction wing, subsequently she was moved to Residential Unit 3. During her time at the prison she continued to self-harm, she banged her head, she punched herself, she made scratches and cuts to herself, she made ligatures and was found with them on two occasions. She found it difficult to cope with the noisy environment and prison regime. On 21st June a neurodiversity specialist met her and created a communications support plan for her. This set out the difficulties she had with noise, smells, food, and physical contact, it suggested ways for people to understand and interact with her. On 4th July Kay cut her arms in the morning, a nurse cleaned her wounds and Kay handed to her a ligature that she had made. At around 6.30pm Kay could not be found and after a search she was located hiding under a table in the association room. She refused to go back to her cell. She was restrained and carried back to her cell by officers. At 7.26pm 3 officers went into her cell and found her hanging, she was cut down and cardio-pulmonary resuscitation is commenced. Paramedics arrive and she is then taken to Southmead Hospital. Kay died on 7th July 2022. During her numerous ACCT case reviews her care plan with support action was never completed. After the control and restraint constant observations were not considered. There was little understanding by the prison staff of Kay�s neurodiversity.	I have sent a copy of my report to the chief coroner and to the following interested persons a Kayleigh�s family b HMP Eastwood Park c Healthcare � Practice Plus Group d Mental Healthcare � Avon and Wiltshire Mental Health Partnership Trust e Ministry of Justice I am also under a duty to send the chief coroner a copy of your response. � The chief coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the chief coroner.	State Custody related deaths \| Suicide (from 2015) \| Mental Health related deaths	HMP Eastwood Park \| Practice Plus Group \| Avon and Wiltshire Mental Health Partnership Trust \| Ministry of Justice
02/06/2023	2023-0178	Andrew Dean	East Sussex	HMP Lewes The Ministry of Justice	On 29 March 2021 I commenced an investigation into the death of Andrew DEAN aged 50. The investigation concluded at the end of the inquest on 31 March 2023. The jury recorded a conclusion of SUICIDE.	On 26th March 2021 at approximately 10.11am in cell A3-10 at HMP Lewes, Andrew Dean was found with a ligature around his neck�[REDACTED]. He was treated at the scene by prison staff, healthcare staff and paramedics. Andrew Dean was declared dead at 11.27am at HMP Lewes.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1.�� Andrew Dean�s partner 2.�� Andrew Dean�s brother 3.�� Practice Plus Group. � 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: HM Prison and Probation Service
14/04/2024	2024-0197	Darren Docherty	Staffordshire and Stoke on Trent	HMP Stoke Heath � Local Authority for Stoke on Trent	On the 1st September 2023, I commenced an investigation into the death of Mr Darren Clifford Docherty. The investigation concluded at the end of the inquest on 8 April 2024. The conclusion of the inquest was a short form conclusion of suicide. The cause of death was: 1a Ligature Suspension	Mr Docherty was released from HMP Stoke Heath on the 4 August 2023. He had a history of mental health difficulties, self-harm and drug abuse. � On his release from prison he had no accommodation. This meant that he was unable to be referred to the Community Mental Health Team or access a GP.On the 10 August 2023 he was found hanging from a tree in a woodland area between Whittle Road and Mollison Road in Stoke-on-Trent.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Family of the deceased; � Stoke-on-Trent Probation Service � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	State Custody related deaths \| Suicide (from 2015) This report is being sent to: HMP Stoke Health \| Local Authority for Stoke on Trent
21/05/2024	2024-0278	Christine McDonald	Cheshire	HMP Styal, MOJ and Inquests Team 1 (Leeds)	On 08 March 2019 I commenced an investigation into the death of Christine MCDONALD aged 55. The investigation concluded at the end of the inquest on 10 May 2024. The conclusion of the inquest was that: � Narrative Conclusion � Suicide � Contributed to by: Failings in communication and/or information sharing between healthcare staff at HMP Styal. Failings in communication and/or information sharing between prison staff at HMP Styal. Failings in communication and/or information sharing between healthcare staff and prison staff. Failure to pass on information in respect of Christine�s daughter�s wellbeing. Failure to assess Christine on her return from Wythenshawe Hospital. Failure to action Christine�s request to see a nurse. Failures by healthcare to follow the clinical guidance in respect of the assessment and/or treatment of Christine�s drug dependency. Neglect � It was also found that the emergency response codes were not used which led to a delay in bringing the required emergency medical equipment, namely oxygen and the emergency bag and there was a significant delay in locating the defibrillator, although these issues did not contribute to Christine�s death.	Christine McDonald was 55 years old at the time of her death on the 3rd March 2019. On� the 1st March 2019 Christine was arrested at her home address and around the time of her arrest had witnessed her daughter fall from third-floor window and was concerned about her. Christine was taken to Blackpool Magistrates Court and sentenced to 12 weeks imprisonment to be served at HMP Styal. Christine had a long history of drug dependency and at the time of her arrest she was known to be a user of Heroin, Crack Cocaine and Amphetamine. On the 2nd March 2019 Christine was taken to Wythenshawe Hospital following concerns raised during a healthcare assessment in HMP Styal. Christine discharged herself from hospital and was returned to HMP Styal. Just after 11pm on the 2nd March 2019 Officers went to speak to Christine in her cell and found her unresponsive, having� tied a ligature [REDACTED]. The emergency response codes were not used and consequently, when Healthcare attended, they were unaware that they were attending an emergency and did not have the necessary emergency equipment with them. Although the failure to use the emergency response codes was not a contributory factor in the death, it caused a delay in providing the necessary medical treatment. Christine was taken to Wythenshawe Hospital but sadly passed away the following day with her family by her side.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � [REDACTED] � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make 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: HMP Styal \| Ministry of Justice
16/07/2024	2024-0488	George Dillon	Hampshire, Portsmouth and Southampton	Hampshire Constabulary National Police Chiefs� Council (NPCC)	On 01 June 2023 an investigation was commenced into the death of George Robert DILLON aged 19.� The investigation concluded at the end of the inquest on 24 April 2024.� The conclusion of the inquest was that: � On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree.� He was the sole occupant of the car.� There is no evidence that any other vehicle was involved.� He suffered catastrophic and unsurvivable injuries.� He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023.	On the evening of Thursday 18th May 2023 the Deceased was driving a VW Golf south along a country road, namely Lee Lane, Romsey, in the vicinity of its junction with Spaniard Lane when at around 22.16 to 22.26 he lost control of the car by reason of his speed on a crest in the road, and hit a large tree.� He was the sole occupant of the car.� There is no evidence that any other vehicle was involved.� He suffered catastrophic and unsurvivable injuries.� He was taken to the Neurosurgical Unit at Southampton General Hospital where he died from his injuries on 20th May 2023.	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�� 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	Hampshire Constabulary \| National Police Chiefs� Council
30/08/2024	2024-0478	Wendy Afford	Berkshire	Happy at Home Community Care Services Ltd.	On 21 November 2023 I commenced an investigation into the death of Wendy Ann AFFORD aged 87.� The investigation concluded at the end of the inquest on 30 August 2024.�� The conclusion of the inquest was that: Wendy Ann Afford had been bedbound for most of the year prior to her death and suffered from complications arising from this, her age and� various� medical� conditions.�� Her� overall� health� and� skin condition deteriorated from June 2024 and Mrs Afford� declined and died on the 15th November 2023 at the Beacher Hall Care Home, Reading.	Mrs Afford was discharged to her home from hospital in February 2023 with a package of care to be provided by Happy at Home Community Care Services.� She lived alone and was bedbound.� She needed personal care and carers attended 4 times per day.� She was discharged with a pressure ulcer which had healed by the 4th� April 2023. In June 2023 she developed pressure damage to her right buttock, this got worse over the course of July and she was admitted to the Royal Berkshire Hospital on the 26th� July 2023 with an infected pressure� ulcer.�Mrs� Afford� remained� in� hospital� until� the� 13th September 2023 and by this time she had become more frail.� The tissue viability team were involved in her care during her inpatient stay. She was discharged to Beacher Hall Care Home for ongoing care. She� still� had� a� pressure� ulcer� and� a� referral� was� made� to� the community tissue viability�nurses�who provided�advice�and assistance to the care home. Mrs Afford�s health declined and she died on the 15th November 2023.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mrs Afford�s family; Berkshire Healthcare NHS Foundation Trust; Beacher Hall Nursing Home; I have also sent it to CQC Legal � 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.	Care Home Health related deaths	Happy at Home Community Care Services Ltd
18/7/2024	2024-0385	Tony Williams	Cheshire	Health and Safety Executive	On 10 December 2020 I commenced an investigation into the death of Tony WILLIAMS aged 45. The investigation concluded at the end of the inquest on 15 July 2024. The conclusion of the inquest was that the death was a Misadventure.	On 2 December 2020, Tony Williams, an HGV driver for�[REDACTED] , was delivering bales of hay to [REDACTED] in Cheshire. Thirty-three hay bales were loaded onto the 45ft HGV at [REDACTED] in Suffolk by the farm director in the presence of Mr Williams, who was experienced in the strapping and loading of Hesston bales. Three bales were loaded width ways, the opposite direction to the rest of the bales, on the back end of the vehicle. On the journey from Suffolk, somewhere along the route an ANPR camera had caught an image of hay overhanging the back of the vehicle. When arriving at [REDACTED], with the assistance of a banksman, Mr Williams reversed down [REDACTED] a public domain road with a known slope comparable to a wheelchair ramp. Mr Williams was witnessed by a Farmhand unstrapping the load when the three width ways bales fell from the back. Two of which fell on top of Mr Williams. The Farmhand who witnessed the unstrapping, removed the bales from Mr Williams with his telehandler and administered CPR with guidance from the ambulance service operator. When the ambulance arrived advanced life saving measures were administered to no avail. He was pronounced dead at the scene at 11:01 hours.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Mr William�s family, Liverpool University, [REDACTED], [REDACTED] and [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.	Accident at Work and Health and Safety related deaths� � � This report is being sent to: Health and Safety Executive
31/01/2023	2023-0421	Evelyn Burcham	Somerset	Health and Safety Executive �Redgrave Court �Merton Road �Bootle �Merseyside �L20 7HS [REDACTED], Department of Health and Social Care House of Commons London SW1A 0AA Care Quality Commission 2 Redman Place London E20 1JQ	On the 28th of December 2022 I commenced an investigation into the death of Evelyn Ann Burcham, aged 96. The investigation concluded at the end of the inquest on the 27th September 2023. The conclusion of the inquest was �Accidental Death� with the medical cause of Mrs Burcham�s death being given as: Ia) Head Injury	Mrs Burcham had resided at Frethey house Nursing Home (�the Home�) since May 2017. She had suffered a stroke in 2016 and her condition had progressively worsened due to dementia. Mrs Burcham was incapable of doing anything for herself and she relied on the staff at the Nursing Home to anticipate and meet her every need and provide her with full care, including; personal care, hoisting, transfer, nutrition etc. She also lacked capacity and could only communicate through incoherent mumbling and facial expressions, which the staff who knew her well at the home had learned to interpret. � The Home is a residential and nursing home which, whilst accepting patients with dementia, is not a dementia specialist service. � On the 14th of December 2022 the Home had organised a carol concert in the communal lounge as part of their Christmas celebrations. It was attended by residents and their families, staff and church volunteers. � Mrs Burcham was brought to the lounge and hoisted into a standard riser- recliner chair. As she lacked any ability to support her own posture she was wedged in with pillows and the chair legs elevated by staff (via the remote control) to prevent her from slipping out. Carers then went to assist other residents to access the lounge ahead of the concert starting. � The riser recliner chair that Mrs Burcham was in appeared to be a fairly standard design; an electric chair plugged in at the mains to enable the mechanism via a remote control, which is attached to the chair via a cord, with a side pocket for storage of the remote control whilst it is not in use. � Whilst Mrs Burcham was in the riser-recliner chair unattended, another resident of the Home has accessed the remote control for the chair. This other resident had dementia which manifested itself in a compulsion to randomly fiddle. The other resident fiddled with the remote control buttons as they were accessible, unlocked and unsupervised and, without any intention or malice (or indeed any appreciation whatsoever of what she had done, because of her own cognitive impairment) managed to elevate the chair to its full rise position and tip Mrs Burcham onto the floor. Mrs Burcham had no power of speech to call for help, nor was she able to support her own weight or break her fall. She landed on her head and sustained a severe bleed on the brain, sadly dying of her injuries ten days later.	I have sent a copy of my report to: (i)�� the Chief Coroner (ii)�� Mrs Burcham�s family � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.	Care Home Health related deaths This report is being sent to: Health and Safety Executive \| Department of Health and Social Care \| Care Quality Commission
02/01/2025	2025-0002	Victor Knowles	Cheshire	Henning Hall Nursing Home Springcare Care Homes Ltd	On the 7th February 2024, I commenced an investigation into the death of Victor William Knowles. � Victor died on the 20th January 2024.� He was 79 years old.� The investigation concluded at the end of the inquest on the 12th December 2024. The medical cause of death was confirmed as 1a Osmotic Demyelination Syndrome caused by 1b Hypernatremia due to 1c Dehydration; and 2 Frailty of old age. � I recorded a narrative conclusion that Victor died of a rare neurological complication of hypernatremia as a consequence of dehydration and malnourishment and that Victor�s death was contributed to by Neglect.	On the 12th of December 2023, Victor was admitted to Henning Hall Nursing home as a short-term placement to inform in his long-term care planning. At the time of his admission Victor lacked mental capacity and was identified as being at high risk of dehydration and malnutrition, requiring assistance to promote his fluid and oral intake.� Plans were put in place for his weight to be monitored and recorded weekly. � The Court heard evidence that on the 2nd January 2024, Victor was seen by his GP and although there was some discussion in respect of his poor dietary intake, the GP was not informed of the 5kg of weight that Victor had lost within the preceding 12 days, nor was the GP provided with the details of the limited amount of fluid that Victor was taking at that time.� � On the 4th January 2024, Victor was booked onto the GP triage list following concerns being raised by staff in respect of his fluid and oral intake.� The Court heard evidence that the GP made three attempts to contact the Home but there was no answer with no follow up being made by the Home in respect of the missed appointment. � The Court heard evidence from the GP that Victor was seen again on the 9th January 2024 by which time he had become too frail for his weight to be measured.� At the time of the review, Victor�s fluid intake was very low but the details recorded by the Home were not provided to the GP so as to form part of his assessment, nor was the GP informed that Victor had become too frail to weigh.� � The Court heard evidence that on the 11th January 2024, Victor was reviewed via telephone by the community dietician who was informed that Victor�s weight had been steady since early December but that he was refusing to eat and required encouragement to drink.� It was accepted that the information in respect of Victor�s weight was not accurate given that he had lost 5kg since his admission to the Home. � Later that day, a telephone call was made by the Home to the next of kin, in which it was reported that Victor was very poorly, his clinical observations indicating very low blood pressure and a high pulse rate.� Evidence was heard that attempts were made that day to contact both the GP and the Urgent Community Response team, but to no avail with no further steps being taken at that time, to obtain medical treatment for Victor. � Overnight, Victor�s condition did not improve, it being noted that Victor was very poorly.� A call was initially made to the GP at 14.53 hours followed by a request for an ambulance at 15.11 hours. � On admission to Hospital, the Court heard evidence that Victor had an acute kidney injury and hypernatremia secondary to being grossly dehydrated and malnourished,�� with Victor having developed osmotic demyelination syndrome, a rare neurological complication of hypernatremia.� � Attempts were made to treat Victor, however his condition continued to deteriorate and he passed away on the 20th January 2024.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:- � The family of Victor William Knowles East Cheshire NHS Trust Henning Hall Nursing Home � I have also sent it to the Care Quality Commission who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Care Home Health related deaths	Henning Hall Nursing Home \| Springcare Care Homes Ltd
16/08/2023	2023-0295	Absolom Duffy	Lincolnshire	Highways AGENCY	On 16 July 2021 I commenced an investigation into the death of Absolom Adolphus Abraham Zephaniah DUFFY aged 21. The investigation concluded at the end of the inquest on 17 May 2023. The conclusion of the inquest was that: � Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 2021 when he exited from Sand Lane, Saxilby onto Doddington Road and collided with another vehicle. Paramedics attended however he died as a result of his injuries.	Absolom Duffy was travelling in his Land Rover Defender motor vehicle on the 8th July 2021 when he exited from Sand Lane, Saxilby onto Doddington Road and collided with another vehicle. Paramedics attended however he died as a result of his injuries.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] � I have also sent it to � who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Road (Highways Safety) related deaths This report is being sent to: Lincolnshire County Council
22/02/2023	2023-0070	Jacqueline Campbell	Milton Keynes	Hilltops Medical Centre, Kensington Drive, Great Holm, Milton Keynes � �� [REDACTED] NHS England National Director for Primary Care and Community Services � �� [REDACTED] Chief Medical Director, Bedfordshire, Luton and Milton Keynes Integrated Care Board	On 04 July 2022 I commenced an investigation into the death of Jacqueline Sharman CAMPBELL aged 56. The investigation concluded at the end of the inquest on 08 February 2023. The conclusion of the inquest was that: � Ms Jacqueline Sharman Campbell died on the 30th June 2022 at her home address. She had battled chronic backpain for more than 20 years. It was difficult to manage. She was prescribed large doses of gabapentin, tramadol and amitriptyline. She was also prescribed fentanyl patches and oral diazepam. She likely inadvertently overdosed on tramadol and that, in combination with the other medicines, all possessing the ability to depress the central nervous system, had the synergistic effect of causing respiratory depression and death.	Ms. Campbell was medically retired. She worked for Transport for London and had an accident over 20 years ago where she injured her back. This resulted in continuing chronic back pain for which she took prescribed medication. Family report that she was not very good at managing this medication. � During the late evening of Wednesday the 29th of June 2022 Jace Campbell, the son of Jacqueline came home and found his mother collapsed in her ensuite bathroom. Other family members have been contacted and came to Jace�s assistance. Paramedics were called but they were unable to save Jacqueline and they confirmed her death on the 30th of June 2022.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons� [REDACTED] I have also sent it to who may find it useful or of interest. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Alcohol, drugs medication related deaths	Hilltops Medical Centre, NHS England, Luton and Milton Keynes Integrated Care Board
12/12/2023	2023-0524	Ruth Perry	Berkshire	His Majesty�s Chief Inspector for Ofsted, [REDACTED] Secretary of State for Education, the Rt Hon Gillian Keegan Chief executive of Reading Borough Council, [REDACTED]	The family requested me to refer to the deceased as Ruth. I will reflect that in this report. I conducted an inquest into the death of Ruth Carla Perry which concluded on 7th of December 2023. I recorded a narrative conclusion as follows: � Suicide, contributed to by an Ofsted inspection carried out in November 2022.	This was the first Ofsted inspection that Caversham Primary School (�CPS�) had had for 13 years. There was previously a policy which meant that schools which had been rated outstanding were not inspected in line with usual timescales. There was a policy change in 2021, and CPS was therefore due an inspection. This was the reason for the inspection in November 2022. � CPS underwent an Ofsted inspection on the 15th and 16th of November 2022, after receiving a phone call to notify them of this at 1pm on 14th November 2022. Ruth�s mental health deteriorated significantly during and after the inspection. She displayed suicidal ideation and planning a few days after the inspection. She sought mental health support, but felt unable to discuss the likely outcome of the inspection in any detail. Ruth had no relevant past mental health history. The records and evidence set out very clearly what the cause of her mental health deterioration was. She took her own life on 8th January 2023. � Other findings which I made in this case included: 1. I referred in questioning to hypothetical schools A and B. Hypothetical school A is good in all areas, but there are safeguarding concerns which can be remedied quickly. Hypothetical school B is dreadful in all respects. The system as it currently stands will mean that these 2 hypothetical schools will receive the same overall label of �inadequate�. For maintained schools, both would face possible academisation and job losses. 2. The lead inspector told the chair of governors that CPS had a robust safeguarding culture and that all children felt safe. We heard different estimates for how long the inspection team believed the safeguarding issues identified would take to remedy. The longest of these was 30 working days. 3. Parts of the Ofsted inspection were conducted in a manner which lacked fairness, respect and sensitivity (these are the terms used in Ofsted�s Code of Conduct). This likely had an effect on Ruth�s ability to deal fully with the inspection process. It is very important to stress here that, although I necessarily had to consider the conduct of the inspectors in this matter, the focus should not be on any individual inspector, but more on the system, policies and training. 4. There is very little training by Ofsted, and no written policy, regarding management of school leader anxiety during inspections. 5. The suggestion that an inspection could be paused for reason of school leader distress was not part of Ofsted�s policy or training. 6. Ofsted�s confidentiality requirements (between inspection and final publication of the report) was a significant issue for Ruth. 7. Ruth�s employer, Reading Borough Council, clearly felt that Ofsted�s decision was wrong and unfair, but did not provide any comment on the draft report, despite asking for the opportunity to do so. 8. The legal test I have to apply is whether I consider it is likely that the Ofsted inspection contributed more than minimally to Ruth�s mental health deterioration and death. I found that it did contribute. 9. An unfavourable inspection outcome in itself would be distressing to a headteacher. However, whilst the outcome of the inspection was a part of Ruth�s distress, it was not the only cause. I remain concerned about: a. The conduct of the inspection itself. b. The current Ofsted system which allows for the single word judgement of �inadequate� to be applied equally to a school rated otherwise good, but with issues that could be remedied by the time the report was published, as to a school which is dreadful in all respects. c. The confidentiality requirement at the time. d. The length of time between the inspection and final report, thus lengthening the period of the confidentiality requirement.	I have sent a copy of my report to the Chief Coroner and to Ruth�s family, via their legal representative. I have also sent this report to the following recipients, who have an interest in this matter: 1. Legal representative for Ruth�s GP. 2. Legal representative for Berkshire Healthcare NHS Foundation TrustI am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Ofsted \| Department for Education \| Reading Borough Council
28/12/2022	2022-0416	Emma Powell	North Wales (East and Central)	His Majesty�s Government c/o Prime Minister�s Office, 10 Downing Street, London SW1A 2AA Tesco PLC, Tesco House, Shire Park, Kestrel Way, Welwyn Garden City, Hertfordshire AL7 1GA	On the 16th Of July 2022 I commenced an investigation into the death of Emma Louise Powell (DOB 22.10.97 DOD 15.7.2). The investigation concluded at the end of the inquest on the 8th of December 2022. The conclusion of the inquest was that the death was the result of an accident, the cause of Miss Powell�s death being recorded as 1(a) Immersion	The circumstances of the death are as follows : � On the 14th of July 2022 at Conwy Morfa, the deceased got into difficulties whilst paddleboarding. The current of the Spring tide resulted in her being unable to make her way to safety and she was recovered from the water after being submerged for a period in excess of ten minutes. She was taken to Ysbyty Gwynedd where her death was confirmed shortly after midnight on the 15th of July.	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.	Other related deaths \| Wales prevention of future deaths reports (2019 onwards)	Prime Minister�s Office \| Tesco PLC
05/04/2022	2024-0019	Sandra Barnett	Lincolnshire	Holme Farm Willow Tree Lane Marsh Chapel Grimsby DN36 SUD	1a. Traumatic Subdural Haematoma (Operated) .	Name of deceased: Mrs Sandra BARNETT � Following an unwitnessed fall downstairs whilst on holiday in Grimsby, which occurred at 22:30 hrs on 16/04/2021 at a holiday let hosted by Airbnb (Holme Farm, [REDACTED]). The deceased was admitted to Grimsby A&E before being transferred to Hull for a decompressive craniotomy and subsequently transferred to RBH on 05/05. Underwent further surgery at RPH. Post op transferred to Critical Care. Sedation was removed however patient did not.wake. An EEG initially showed seizure activity. Treated with antiepileptics but her conscious level did not improve. Further imaging CT and MRI scan showed further evidence of haemorrhage in brainstem. A family conference resulted in the decision for EOL care and treatment was withdrawn. Patient continued to deteriorate and died. Death verified 21/05/2021 at 1857 hrs.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Other related deaths This report is being sent to: Holme Farm
12/10/2023	2023-0398	Norma Kyte	South Yorkshire (Western)	Home Manager, Broomcroft House Nursing Home, 414 Ecclesall Road South, Sheffield, S11 9PY [REDACTED] General Manager, UK Care Services, Bupa Care Homes	On 9 June 2023 I commenced an investigation into the death of Norma Kyte, 87 years old. The investigation concluded at the end of the inquest on 6 October 2023. The conclusion of the inquest was death by natural causes. The medical cause of death was 1a alzheimer�s disease, age related frailty 2 fall.	Norma Kyte died on 4 June 2023 at Broomcroft House. On 2 May 2023 she had an unwitnessed fall at the nursing home. This fall did not trigger the sensor mat which had been placed on the floor and therefore was not identified by staff until she was checked upon. The mat used on the floor had been deemed appropriate to be used in this way by the nursing home, but did not cover all the area by the bedside and would not trigger unless it was directly stood upon. The care home were unable to identify if this was used in accordance with manufacturers instructions. Norma was taken to Northern General Hospital for an x-ray and diagnosed with a right supracondylar femoral fracture. She was discharged with a full length cast on her leg. � Following this she was seen on numerous occasions by the GP for vacant episodes, agitation and reduced oral intake. Treatment was given but she continued to deteriorate. The Care Home Manger confirmed that when Norma returned to the home she had completely changed in presentation and that this had had a big impact upon her. She was last see on 2 June by the GP where she had further reduced responsiveness and oral intake. She continued to decline and passed away on 4 June 2023.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Hilary Sayer the daughter of Norma Kyte. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: BUPA
02/10/2023	2023-0362	Jack Zarrop	West London	Home Office National Police Chiefs� Council NHS England	An investigation was commenced into the death of Jack Peter Zarrop, aged 23. The investigation concluded on 29 September 2023. The conclusion of the jury in the inquest was: � Suicide. We, the jury, find the: 1.�Failure to remove the bedsheet and close the hatch allowing Jack to create a ligature point 2. Failure to refer to Liaison and Diversion services in Central and North-West London and the failure to open an ACCT whilst in prison custody, either of which would have triggered a more thorough risk assessment 3. The difficulties accessing relevant and important information relevant to J. Zarrop�s history, both medical and custodial were the main contributing factors to the death of J. Zarrop. The medical cause of death was 1a Aspyhxia 1b Hanging	Jack had a history of difficulties with his mental health and a history of alcohol abuse. He had made multiple previous suicide attempts, including a very serious previous suicide attempt of hanging.� He had previously been arrested in December 2020 and assessed by Liaison & Diversion services whilst in Police custody. After he was remanded in custody, he was placed on an ACCT twice in prison. After his release from prison on 14th February 2021, he was referred to the community Mental Health Crisis service by his GP and also had another very recent suicide attempt in the form of an overdose of anti- depressants about a week before he was again arrested on 17th March 2021. In Police custody, he was seen by a Custodial Nurse Practitioner (CNP) who had very limited training in Mental Health and the recognition of the risk of suicide. The CNP was working alone and not alongside a doctor. The CNP assessed Jack�s risk as low. The CNP also did not refer him to Liaison & Diversion services, which the jury found that probably contributed to Jack�s death. A Forensic Medical Examiner in Police custody subsequently assessed Jack�s risk as high. Jack was again remanded in custody. Despite Jack�s significant risk history as well as other significant risk factors, such as being young, withdrawing from alcohol and early days in custody, no ACCT was opened by prison or healthcare staff, who were overly reassured by Jack�s presentation.� An agency healthcare member of staff had no training in the ACCT process. The jury found that the failure to open an ACCT by prison and healthcare staff probably contributed to Jack�s death and that, on the balance of probability, the risk of suicide was not adequately identified for Jack. These findings by the jury were based on the over-emphasis by prison and healthcare staff on Jack�s presentation against clear and evidenced previous suicide and self-harm risks and attempts, which were available to relevant police, prison and healthcare staff. The Court heard evidence that 65% of primary care healthcare staff in prison are agency staff. The Home Office circular from 2003 relating to the use of Custodial Nurse Practitioners refers working alongside doctors and being specifically trained for their role. However, the Circular makes no mention of assessing the risk of suicide or self-harm in its Annex which lists competencies.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � 1. Jack Zarrop�s daughter 2.�[REDACTED]�� . 3.�Ministry of Justice 4.�His Majesty�s Prison and Probation Service 5.�The Commissioner of Police of the Metropolis 6.�Practice Plus Group 7.��West London NHS Trust 8.�Barnet, Enfield and Haringey Mental Health NHS Trust 9. [REDACTED] 10.�Forward Trust 11.��Central and North West London NHS Foundation Trust 12.�Serco � 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: Home Office \| National Police Chief�s Council \| NHS England
08 /03/2024	2024-0150	Rose Hollingworth	Inner North London	HomeDotCare Limited, Unit 11, Studios Holloway, Hornsey Street, London, N7 8GR � Islington Social Services, London Borough of Islington 222 Upper St, London N1 1XR � Care Quality Commission, 2 Redman Place Stratford London, E20 1JQ	On 14th April 2022 Assistant Coroner Jonathan Stevens commenced an investigation into the death of ROSE MARY HOLLINGWORTH [age 83]. The investigation concluded at the end of the inquest on 26th July 2023. The conclusion of the inquest was of death by natural causes.	ROSE HOLLINGWORTH was a frail lady with significant co-morbidites but was able to live in her own home because of package of care provided by HomeDotCare Limited, commissioned by Islington Social Services (London Borough of Islington). � In the morning of 3rd January 2022, a carer employed by HomeDotCare Limited came to ROSE HOLLINGWORTH�S home as part of the package of care but upon finding ROSE HOLLINGWORTH apparently asleep left the property (after discussing the situation with the staff at HomeDotCare on the phone) without carrying out any welfare checks or providing any care. The carer returned to ROSE HOLLINGWORTH�S home later the same day and only then, when finding ROSE HOLLINGWORTH still in bed, did she undertake welfare checks and found ROSE HOLLINGWORTH to be unresponsive, breathing noisily and covered in vomit/haematemesis. � An ambulance was called and ROSE HOLLINGWORTH was admitted to Whittington Hospital where she died the following day, namely 4th January 2022. � The medical cause of death was established at the inquest to be: 1 (a) spontaneous intra-cerebral haemorrhage 2 Hypertension, Ischaemic Heart Disease, Chronic Obstructive Pulmonary Disease, frailty. The inquest heard evidence from [REDACTED], Consultant in Acute Medicine and General Internal Medicine at Whittington Hospital that ROSE HOLLINGWORTH had suffered a spontaneous catastrophic and un-survivable bleed and at no time would any medical intervention have been able to reverse that. Accordingly, even if the carer had carried out proper welfare checks when she came in the morning, and raised the alarm, it would not have affected the outcome in the case and ROSE HOLLINGWORTH would still have died. � At the inquest the following findings were made: � There were significant failings in the care give to ROSE HOLLINGWORTH. In particular: � The carer should have conducted a proper welfare check on her first care visit. The carer should have been concerned that ROSE HOLLINGWORTH was not up and waiting for the arrival of the carer as she would normally have been. The carer should have checked ROSE HOLLINGWORTH�S catheter bag, which was found later found to have 1-2 days of urine. The carer should have made sure that ROSE HOLLINGWORTH took her medication. The carer should not have been told by HomeDotCare when she called to leave ROSE HOLLINGWORTH and return at lunchtime. The carer should have provided basic first aid at the scene. � The failings demonstrated a poor standard of care which in other circumstances could have delayed potentially lifesaving intervention and treatment. The carer assigned on the 3rd of January 2022 was a Somali speaking carer who required a Somali translator in order for her to give evidence at the inquest, raising concerns that the carer lacked the ability to properly and safely communicate with ROSE HOLLINGWORTH in English when attending to her care needs.	I have sent a copy of my report to the Chief Coroner and to the following Interested Parties, [REDACTED] nephew of the deceased and [REDACTED] Niece 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.	Care Home Health related deaths This report is being sent to: Home Dot Care Limited \| Islington Social Services \| Care Quality Commission
11/10/2024	2024-0554	Kingsley Imafidon	North London	Homerton Healthcare NHS Foundation Trust The British Society of Gastroenterology The Royal College of Radiologists The Royal College of Pathology	On 17 January 2024 an investigation was commenced into the death of Kingsley Efosa Imafidon. The investigation concluded at the end of the inquest on 4 October 2024. The medical cause of death was: � 1a) Intra-abdominal haemorrhage � b) Post liver biopsy for jaundice � c) Liver cirrhosis � d) � II) Sickle cell disease � I recorded the following narrative conclusion: � Kingsley Efosa Imafidon had a medical history of homozygous sickle cell disease. On 29 November 2023, Mr Imafidon underwent a scheduled liver biopsy in order to investigate potential liver disease. Part of the device during the biopsy was deployed outside of the liver which later led to the procedural complication of bleeding into the peritoneal cavity, which led to Mr Imafidon�s death.	Kingsley was born with Homozygous Sickle Cell Disease (HbSS). In May 2023 his liver function tests were noted to be significantly deranged with worsening jaundice and he was referred to the gastroenterology team at Homerton Hospital. He underwent non-invasive imaging (ultrasound elastography) on 22 November 2023 which was suggestive of underlying cirrhosis. Blood tests also identified that his bilirubin was high and his elastography was high, consistent with cirrhosis. It was confirmed that a liver biopsy was required to understand the likely cause of the liver disease. � Kingsley underwent a clotting screen on 27 November 2023 prior to the biopsy to check that his INR was below 1.4 so the procedure could take place, in accordance with Homerton Healthcare NHS Foundation Trust�s (�the Trust�) policy. Kingsley�s INR on this date was 1.3. The liver biopsy took place on 29 November 2023 and the circumstances of this are outlined in the narrative conclusion in the box above, although these findings were not known until after the procedure had taken place. � Following the procedure Kingsley was transferred to the Medical Day Unit where he remained for four hours before being discharged at 16:30. This was the standard period of observation for all patients. � On 2 December 2023, Kingsley�s family visited him at his home address and found him lying unresponsive in his bed. The post mortem examination found evidence of extensive fresh haemorrhage into the free peritoneal cavity following the biopsy, which the post mortem report indicates was the immediate cause of death.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Kingsley�s family � I have also sent it to [REDACTED] at the Liver Unit, University Hospitals Birmingham NHS Foundation Trust who I believe may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths	Homerton Healthcare NHS Foundation Trust \| The British Society of Gastroenterology \| The Royal College of Radiologists \| The Royal College of Pathology
08/02/2024	2024-0076	Ethel Reed	East Riding and Hull	Hull University Teaching Hospital NHS England Care Quality Commission CSC (providers of Lorenzo)	On 7th March 2023, an inquest was opened and adjourned into the death of Ethel Doreen Reed aged 93 years. The investigation concluded at the end of the inquest on January 26th, 2024, The conclusion of the inquest was Accidental Death. � Box 3 of the Record of Inquest read: � Ethel Doreen Reed died at Holy Name Community Rehabilitation Centre, Hall Road, Hull from a chest infection which developed from fractured ribs following an unwitnessed fall at home. � Her medical cause of death was recorded as: � 1a Chest infection 1b� Rib fractures 1c II�� Fall, Chronic Obstructive Pulmonary Disease, Hypertension, Transient Ischaemic Attack, Ischaemic Heart Disease, Atrial Fibrillation	Ms Reed had a fall at her home address on 22nd January 2023. She was taken to Hull Royal Infirmary and she was seen in A&E, the Acute Medical Unit, Frailty Assessment Unit for assessment but was deemed too poorly for that ward and was transferred to Ward 90.She had sustained rib fractures which had caused a pneumothorax and she had other co morbidities which were treated on Ward 90. The rib fractures caused an infection to develop in her lungs and Mrs Reed developed pneumonia. Whilst on ward 90 she began physiotherapy and was mobilising and able to eat and drink with minimal support. She was assessed as medically fit for discharge on 3rd February 2023, but she required more physiotherapy and support and so was transferred to a new no criteria to reside ward, Ward H130E in Hull Royal Infirmary. Whilst on Ward H130E Mrs Reed contracted Covid-19. (positive PCR 19/02/23, negative 23/02/23) and this set her discharge back as she had been planned for discharge to a residential rehab setting on 19/02/23. Mrs Reed was seen by the medical team on 24/02/23 as nursing staff had concerns. Mrs Reed was visibly dehydrated, drowsy, tachycardic and her blood tests showed signs of infection. She was assessed as now not medically fit for discharge however instead of being transferred on to a medical ward she was discharged on 26th February 29023 to Holy Name Community Rehab Centre in Hull. She was not medically fit for discharge and indeed should not have been discharged. The fact that she was very poorly was recognised as such upon arrival at the centre. The centre staff requested an urgent medical review and Mrs Reed was placed on end of life care and very sadly died on 2nd March 2023 in the centre.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Ethel Doreen Reed, Hull University Teaching Hospitals Community Health Care Partnership � as well as the agencies identified at the top of this report. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Hull University Teaching Hospitals NHS Trust \| NHS England \| Care Quality Commission \| CSC
24/11/2024	2024-0652	Colin Wiles	City of Kingston Upon Hull and the County of the East Riding of Yorkshire	Hull University Teaching Hospital NHS England East Riding of Yorkshire Council Adult Social Care and Health � I am also sending this to Yorkshire Ambulance Service and Humberside Police Right Care Right Person lead as it may be of interest to these agencies and the family of Mr Colin Wiles.	On 11th April 2023 an inquest was opened and adjourned into the death of Colin Wiles aged 79 years. The investigation concluded at the end of the inquest on 25th October 2024, the conclusion of the inquest was a narrative conclusion. � Conclusion: Narrative � Colin Wiles died at Hull Royal Infirmary following admission for a collapse at home. Multifactorial issues led to a worsening of pre-existing health conditions and hypothermia which were contributed to by self-neglect. � � His medical cause of death was recorded as: � 1a. Type 2 Respiratory Failure 1b. Chronic Obstructive Pulmonary Disease and Hypothermia 2.�� Frailty and Chromic Kidney Disease; Paranoid Schizophrenia	Colin Wiles lived alone in a home he owned. He had a history of diagnosed mental health and was concordant with medication for Schizophrenia. He enjoyed a good relationship with his mental health nurses and GP and was deemed capacitous throughout his treatment in recent years. � Colin had a good and loving relationship with his daughter and with his sister. � Colin elected to live in a house which did not have fully functioning mains services due to a variety of reasons. He received advice on his living situation from various agencies, but he appeared to be content in his way of life. This self-neglect however meant that he did not always keep his house warm although he did have a coal fire and access to oil heaters, and he did cook his own meals when not at family members� houses. There had been attempts at helping Colin access repairs for his house following various admissions to hospital and a safeguarding referral was made by the Safeguarding Adults team at Hull Royal Infirmary on 13th February 2023 as Colin was about to be discharged home from hospital and his house needed work. The Independence and Advice Hub were to screen that referral, but Colin was discharged home before contact was made with him. � On 6th March 2023 Colin was assigned a social worker and support was offered. Colin was offered alternative living arrangements for a short while but declined with capacity to make his own decisions. � On the 7th March 2023, the social worker once again visited Colin, and this time support was accepted from the Red Cross. On 8th March Colin was discharged home. Due to ongoing concerns a Vulnerable Adults Risk Management (VARM) meeting was suggested. � The Red Cross did support Colin but raised concerns about his house. Colin declined further support on 10th March 2023 but said he knew what to do if he needed support in the future. � A VARM meeting was not held, which was an accepted missed opportunity by East Riding Adult Social Care and Health. � Colin�s hospital admissions prior to his death concerned a general decline and hypothermia and he was warmed up at hospital. � Colin�s daughter arranged to visit Colin on 26th March but upon attendance there was no response to knocking or phone calls. She rang the police with a concern for welfare call. She was advised this was a health concern and as such under the Right Care Right Person Policy she should ring for an ambulance which she duly did at 17:57. The call was answered at 17:59 which constituted a delay of 1 minute and 50 seconds. � The call was coded as a Category 3 call, which on the information provided was the correct category. The caller was advised the service was extremely busy but was not advised how long the delay was likely to be. � Calls were made to the patient, but the line was constantly engaged as reported by his daughter. � At 03:35 on 27th March 2023 an ambulance arrived at Colin�s house. This was response time of 9 hours and 38 minutes was accepted by Yorkshire Ambulance to be an excessive response time. � Colin was seen through the window collapsed and the fire and rescue service were summonsed by ambulance to attend and effect entry which they did at 04:00 hours. Colin was critically unwell when the ambulance crew assessed him, and he was conveyed under blue lights and sirens Hull Royal Infirmary who were pre alerted by the ambulance that he was en route. � Despite best efforts at Hull Royal Infirmary, Colin sadly passed away at 15:00 hours on the 27th March at Hull Royal Infirmary.� �� Due to excessive handover times at Hull Royal Infirmary on that date Colin was not handed over to Emergency Department staff until 05:48 hours, having arrived at the emergency Department at 04:27 hours. This was a delay of 1 hour and 21 minutes. � At 02:58 on 27th March 2023 the CSP level was escalated to Level 3, as Category 3 response times had increased to 10 hours and 5 minutes. A total of 160 ambulance hours were lost on that date waiting for patient transfer at Hull Royal Infirmary which equates to 16 x 10 hr ambulance shifts.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: the family Colin Wiles, Yorkshire Ambulance Service and Humberside Police as well as the agencies identified at the top of this report. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Emergency services related deaths (2019 onwards) \| Hospital Death (Clinical Procedures and medical management) related deaths	Hull University Teaching Hospital \| NHS England \| East Riding of Yorkshire Council Adult Social Care and Health
30/01/2024	2024-0044	Sylvia White	East Riding and Hull	Hull University Teaching Hospitals NHS Trust	On 3rd November 2023 I commenced an investigation into the death of Sylvia Linda WHITE, aged 92 years. The investigation concluded at the end of the inquest on 26th January 2024. � The conclusion of the inquest was: Accident � The following findings of fact were made: Sylvia Linda WHITE was 92 years of age, she was partially sighted but maintained a level of independence at home with the assistance of carers. Mrs White had been discharged from hospital recently (day before her birthday, which would have been 04/10/2023), but evidence heard that the discharge papers did not report the increase in her frailty and the decrease in her mobility. At the beginning of the inquest it was unknown that the issue of discharge summaries may be relevant. Manager of the care company raised concerns that it was not uncommon for discharge summaries to be inadequate in assessing the ongoing care changes. The carer felt that the risk assessments should have changed after hospital but they were not. Carer attended on the evening of Thursday 12th October 2023, Mrs White was in bed. She was given medication but did not wish to use the commode. Mrs White was capable of getting out of bed and using the commode herself. The commode should have been placed next to the bed. Notes said it should have been placed within reach but were not specific about locations. The following morning Friday 13th October 2023 a carer attended and discovered Sylvia pinned to the floor by an upturned wardrobe. The commode looked to have been placed in the corner of the room, but was upturned. The wardrobe had never shown signs of instability. Mrs White had never moved the commode herself in the past. There was no reason to think that she had moved it herself on this occasion. A coroner is unable to deal with what is possible, and it would be unsafe to say what definitely happened as Mrs White had no recollection, but it is likely that Mrs WHITE has slipped, possibly while using the commode, and as she fell inadvertently pulled the wardrobe down on top of her. Her dressing gown was hung on the door handle and she may have pulled on this. Mrs White wore a lifeline device but the position of the wardrobe meant she was unable to activate it. I note that, on discovery, the carer lifted the wardrobe, called emergency services and the family, while reassuring Mrs White and keeping her warm and stable. Mrs White had sustained a significant head injury but was unsuitable for surgical intervention. Box 3 of the record of inquest read: Sylvia Linda WHITE was 92 years of age and partially sighted. She maintained a level of independence at home with the assistance of carers. On 13th October 2023 at 0758 a carer discovered Mrs White pinned to the bedroom floor by an overturned wardrobe which she appeared to have accidently pulled down on top of herself during some form of fall or slip. Mrs White was conveyed to Hull Royal Infirmary and found to have a traumatic subdural haemorrhage. The bleed progressed and Mrs White was placed on palliative care. She died on 28th October 2023. � Her medical cause of death was recorded as: 1a Traumatic Subdural Haemorrhage 1b Unwitnessed fall 2 Frailty of great old age, cognitive impairment, chronic kidney disease, congestive cardiac failure	Sylvia Linda WHITE was 92 years of age. She maintained her independence at home but had carers visit 4 times a day. She was mobile but used aides. She was partially sighted, having problems in both eyes. As outlined above Mrs White was found by a carer on the morning of Friday 13th October 2023 pinned to the floor by a wardrobe. She sustained a head injury and died on 28th October 2023 in hospital. There was no issue with her care in hospital leading to her death.	I have sent a copy of my report to: The family of Sylvia Linda WHITE The Chief Coroner Hale Care The Safeguarding Department of the Local Authority The CQC The ICB for Humber NHS National England Director 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: Hull University Teaching Hospitals NHS Trust
10/11/2023	2023-0439	Elizabeth Watson	East Riding and Hull	Human Resources, [REDACTED]	On 9th December 2022 I commenced an investigation into the death of Elizabeth Anne WATSON, aged 33 years. The investigation concluded at the end of the inquest on 9th November 2023. � The conclusion of the inquest was: Suicide � Box 3 of the record of inquest read: On 5th December 2022, Elizabeth Anne WATSON �Lizzie�, jumped [REDACTED] She was declared deceased [REDACTED]. Lizzie was 33 years of age. � Her medical cause of death was recorded as: 1a Extensive External And Internal Injuries 1b Fall From Height	Elizabeth Anne Watson �Lizzie� was intelligent and fun-loving. She trained as a primary school teacher. � Lizzie began to suffer from anxiety and sleeping problems. Her mental health declined in 2019 causing her to become withdrawn from friends and work. In September 2022 it was agreed with her husband that their relationship was over and but they remained living in the same house by arrangement. On 3rd December 2022 there was a substantive argument. It was agreed that her husband would leave the house. The following day the couple talked. While the breakdown of the relationship was distressing it was believed that the situation had settled and decisions had been made. Lizzie appeared calm, she informed family members she would not be going to work the next day as she wanted to rest. � On Monday 5th December 2022 Lizzie attended the Humber Bridge. Security staff in the control room monitored her for a matter of minutes but before assistance was requested from colleagues to approach Lizzie she jumped from the bridge, landing on Cliff Road. Lizzie was declared dead at the scene.	I have sent a copy of my report to: �� The Chief Coroner �� The family of Elizabeth Anne WATSON �� Yorkshire Ambulance Service � Right Care Right Person Lead �� Humberside Police � Right Care Right Person Lead �� 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: Human Resources
13/09/2024	2024-0494	Paul Batchelor	Surrey	In respect of first concern: [REDACTED], Interim Chief Executive, Care Quality Commission� [REDACTED], Chief Executive Officer, Medicines and Healthcare Products Regulatory Agency In respect of second concern: [REDACTED], Chairman, The Red House (Ashtead) Limited	INQUEST An inquest into Mr Batchelor�s death was opened on 13 July 2023.� The inquest heard evidence on 26 January, 19 June, 11 July 2024 and� concluded on 14 August 2024.�� The medical cause of Mr Batchelor�s death was: 1a. Bronchopneumonia and Positional Asphyxia With respect to where, when and how Mr Batchelor came by his death it was recorded at Box 3 of the Record of Inquest as follows:� Paul Rodney BATCHELOR died at his care home in Ashtead,� Surrey. He had been assisted to bed by care home staff at around� 2100 hours on 27 June 2023. Mr Batchelor slept in an extended� profile bed which utilised a mattress extension to cover the gap� between the standard mattress and the footboard. His bed was�also fitted with bedrails. Later that same night he manoeuvred� himself across the foot end of his bed, lying on the mattress� extension. The bed did not have a deck in place supporting the� mattress extension. As a result the mattress extension fell through� the bed extension frame and Mr Batchelor became wedged in the� gap which was then created between the standard mattress and� the footboard. Although he cried for help for over an hour his cries were not responded to and he died of positional asphyxia and� bronchopneumonia. He was found dead in that position shortly� before 2330 hours on 27 June 2023 and his death was formally� recorded by paramedics on 28 June 2023 at 00.01 hours that night.�� The inquest concluded with a narrative conclusion of �Accident contributed to by neglect�	During the course of the inquest the court heard that Mr Batchelor was a frail elderly man in a care home for respite care. He was provided with� an Invacare Medley Ergo nursing care bed set up with an extended� profile. To cover the gap between the end of the standard mattress and� the extended foot end of the bed a mattress extension (or bolster) was� fitted. The gap being approximately 20 cms wide.�� When he was put to bed on 27 June 2023 by care home staff, the mattress� extension was in place. Shortly before 23:30 hours on 27 June 2023, Mr� Batchelor was found lying unresponsive on his side across the foot end of the bed with his feet over the bedrails and part of his side and arm� wedged in the gap between the standard mattress and the foot board.� The mattress extension had fallen through the bed extension frame to the� floor.�� Inquiries of the manufacturer of the bed, Invacare, indicated that the bed� should have been fitted with an extension deck which would have� supported the mattress extension (or bolster) and prevented it falling� through the bedframe. This would have been part of the original mattress support extension kit.� The court heard that the care home was unaware that the bed when� extended required a deck to support the mattress extension. The bed had� been used in this format for many years. There was no memory of a� supporting deck ever being in place and when the mattress extension was inserted into the gap the standard mattress and the extension mattress� appeared stable supporting each other. Unfortunately, under the pressure of Mr Batchelor�s weight the mattress extension slipped through to the� floor creating a gap into which he became wedged.�� The Court also heard that between 2205 and 2315 hours on the night of� his death Mr Batchelor�s numerous cries for help went unattended. For� much of this time staff were undertaking their nighttime routine.� However, the evidence revealed that a carer heard his cries at 2305 hours that night, but she did not open the door or go into his room as it was� said she was frightened of him.	COPIES� I have sent a copy of this report to the following: 1. Chief Coroner�� 2. Mr Batchelors family�� 3. Invacare Corporation� 4. DHG (Talley Group Limited)	Care Home Health related deaths \| Product related deaths	Care Quality Commission \| Medicines and Healthcare Products Regulatory Agency \| The Red House (Ashtead) Limited
31/01/2023	2023-0034	Samantha Boazman	Leicester City and South Leicestershire	Inmind Healthcare Group	On 29 October 2021, I commenced an investigation into the death of Samantha Jane BOAZMAN aged 54. The investigation concluded at the end of a 10 day inquest on 27 January 2023. The conclusion of the jury was: � �Death by misadventure. We find that there was gross neglect due to a continuous sequence of shortcomings, including a lack of adequate training on the risks and triggers of patients. Failure to remove ligature risks from bedrooms. Inadequate induction and training of temporary staff�.	Samantha Boazman had a diagnosis of Emotionally Unstable Personality Disorder and Dissocial Personality Disorder. She had had a 35 year history with mental health services. Samantha arrived at Sturdee Community Hospital (a locked female rehabilitation ward) in June of 2020, when her community placement had broken down and she could no longer be safely managed within the community. � At the time of her death, Samantha was detained under s.3 of the Mental Health Act. � On 17th September 2021 whilst on s.17 leave Samantha walked in front of a slow-moving vehicle, she was admitted to A&E with a minor injury to her knee and head injury where she had fallen backwards. She was discharged the same day. � On return to Sturdee Community Hospital Samantha was placed on 15 minute observations but was found in her bathroom [REDACTED] Samantha was moved to a safety room. On 14th October 2021 Samantha returned to her normal bedroom, room 5. � Observation levels were reduced from 15 minutes to 30 minutes on 21st and 22nd September, and then reduced to hourly observations on 23rd September 2021. The RAG rating records Samantha as being on hourly observations from 23rd September to the date of her death. � On 20th September 2021, Samantha was denied access to �cables/chargers�. The Jury heard evidence that something coloured red on the RAG rating was a �high risk�. Cables/chargers were highlighted red and remained contraband items from 20th September to the point of Samantha�s death. � Samantha found transitions difficult to go somewhere she didn�t know. On 21st October 2021 Samantha was informed that she would be moving to Aylestone Flats within the ground of Sturdee Community Hospital in preparation for moving to the community in the future. A Senior Registered MHN told the Jury that the thought of moving destabilised Samantha. � Samantha had heightened sensitivity as part of her Emotionally Unstable Personality Disorder, so a small thing (not receiving a text message) would be felt more strongly. Her Psychologist saw Samantha on the 21st October and described Samantha as anxious and the reasons for this were not receiving responses to her text messages and also leaving the hospital for a future placement (yet to be identified). � Samantha had been more agitated than usual over the course of the previous week and seeking staff support quite a lot. � No one could recall a discussion about Samantha�s risk at the risk management meeting of 22nd October 2021 and if there was a discussion about Samantha�s risk, her risk rating wasn�t changed on the RAG document. � Various staff gave evidence as to Samantha�s presentation on the 22nd October 2021, for example: Samantha was at around 3pm almost irritable; very unsettled and had been more agitated in the days prior to her death and seeking more 1-1 interactions. Samantha was described as unsettled, kept pacing and crying, this was different to what Samantha was like before. Samantha was said to be �very very� anxious walking up and down asking for the doctor or the nurse in charge. � The CCTV evidence of Samantha on 22 October 2021 between 15.57 hours and 17.33 hours (when Samantha was last seen) showed that between 15.57 and 16.29 hours Samantha can be seen pacing the corridor 27 times within the 32 minute period, and between 16.29 and 17.33, a 64 minutes period, she can be seen pacing the corridor 70 times � more than 1 x per minute. � Health care assistants who were allocated general observations would be allocated these within a 1-hour period, for example 4pm to 5pm. The Jury heard how healthcare assistants had to observe and record the hourly observation for a patient on the hour every hour, none were told to record the actual time they observed the patient, nor was that the Inmind Healthcare Group Policy for Sturdee Community Hospital in place at the time. Healthcare assistants would locate the patient 5 minutes before the hour period was up and then record their observation on the hour and then move to their next patient. As far as the purpose of conducting observations, the evidence of the healthcare assistants was that they needed to observe that the patient was safe and if the patient was sleeping, to check if the patient was breathing. Health care assistants were to record the location and what the patient was doing and also to record if the healthcare assistant interacted with the patient and anything else meaningful. If a patient was engaged with� something� (eg: watching tv) there wasn�t an expectation to disturb the patient to interact with them. � There was a period of 1 hour and 12 minutes between Samantha closing her bedroom door and it being opened by a healthcare assistant and no was seen entering Samantha�s room during that time. No one observed her. � Samantha was found at 18.45 hours in her bathroom on 22nd of October 2021 [REDACTED]. � A nurse and healthcare assistant answered the alarm at 18.47, just under 2 minutes. There were difficulties in entering Samantha�s bathroom because she was behind the door. � The 999 call to East Midlands Ambulance Service was received at 18.53 hrs, 8 minutes after the alarm was raised. � A trained paramedic co-incidentally arrived at the hospital to work in a different capacity and went to assist, arriving at Samantha�s bedroom at 18.53 hours, the same time as the 999 call was being made. The Jury hard in evidence that there was no CPR in progress when she arrived. The paramedic said that ILS training was that you should commence early CPR. � The emergency response bag was delayed in being brought to the scene due to being situated on a different ward which required access to another building through locked doors. The defibrillator was being attached during the 999 call and at the point the trained paramedic arrived at the scene. � CPR was commenced at a time at least 8 minutes after the alarm was raised, and at a time at least 6 minutes after the alarm was answered. The defibrillator advised no shock indicating that there was no electrical activity within Samantha�s heart (asystole). A second round of CPR as advised by the defibrillator, was commenced, but Samantha�s pupils were fixed and dilated, she had mottled skin, which she described was a bruising effect when the body has been lying for some time and as advised by the Resuscitation Council UK, CPR was ceased to preserve Samantha�s dignity. � Paramedics attended and Samantha was pronounced dead at 19:15 hours.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons i.�The family of Samantha Boazman [REDACTED] [REDACTED] iv. Care Quality Commission I have also sent it to East Midlands Ambulance Service 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)\| Mental Health related deaths	Inmind Healthcare Group
29/02/2024	2024-0115	Daniel Tucker	Nottingham City and Nottinghamshire	Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust � The Rt Hon Victoria Atkins MP, Secretary of State for the Department of Health and Social Care � Chief Executive, NHS England � Chief Executive, OFCOM	On 11 May 2022 I commenced an investigation into the death of Daniel Mark Edward TUCKER aged 24. The investigation concluded at the end of the inquest, conducted before a jury, on 06 February 2024. The jury returned a narrative conclusion.	Daniel (referred to as Dan at the request of his family) was detained pursuant to s.2 of the Mental Health Act 1983 on Saturday 9th April 2022 and admitted to Redwood 1, Highbury Hospital, Nottingham the following day. He had a diagnosis of Emotionally Unstable Personality Disorder (EUPD) and a long history of mental ill health, including multiple instances of self-harm and suicidal thoughts and behaviour. Following a period of relative stability, he presented at A&E on 5th April 2022 after an episode of deliberate self-harm. He disclosed suicidal thoughts. He was referred to the Crisis Resolution Home Treatment Team that day but was detained on 9th April after disclosing that he had not only an intention but a plan to end his life, details of which he declined to disclose. � Due to previous negative experiences on Redwood 1, Dan requested a move to another ward. He declined nearly all attempts by staff to engage with him and was consistently described as low in mood, very withdrawn and largely confining himself to his bedroom. He was physically (though not formally) discharged following a Ward Round on 22nd April 2022. A clinical psychologist present at that Ward Round gave evidence that she raised concerns that his mental state and demeanour were not conducive to imminent discharge. Dan left Highbury Hospital at around 17:55 that day. At approximately 20:30, he ingested a lethal quantity of [REDACTED] which he purchased [REDACTED] prior to his detention and admission to Redwood 1. � The jury found the following failings in Dan�s care (the first four of which were admitted) contributed to his death:� More should have been done to try and effect the move from Redwood 1 to another hospital/ward in line with Dan�s wishes. � There was a failure to allocate a Named Nurse and/or a failure of the allocated named nurse to carry out a 1:1 session with Dan during his admission. � There was a lack of exploration in the Ward Round on 22 April 2022 and/or a lack of documentation of an exploration in the Ward Round of the �plan� that Dan had to end his life before his admission. � There was a failure by ward staff to hand over information regarding a threat to ligate (noted in the handover sheet from 20 April 2022) to the Ward Round on the 22 April 2022. � A failure to record and take appropriate action following significant risk-related incidents (Daniel expressing an intention to self-harm) which occurred during Dan�s admission. � A failure to take proper account of all available relevant information concerning Dan�s risk when assessing his risk prior to discharge. � The jury also found the following failings (the first three of which were admitted) but did not find these to have contributed to Dan�s death: � A failure to update Dan�s ward specific Care Plan and Risk Assessment documentation in RIO during his admission. � Dan had a Crisis Care Plan developed in August 2018 and updated in January 2019. There was a failure to update it in preparation for his discharge on 22 April 2022. � A failure to adequately discuss Dan�s risk with Dan�s carer prior to discharge. � A failure by the Trust to engage adequately with Dan�s family and/or carers either during his admission on Redwood 1 and/or at the point of discharge. � The inquest heard evidence that Dan had openly discussed his plans to end his own life on a chat forum of the [REDACTED] while detained at Highbury Hospital. It appears he also obtained information on [REDACTED] as a method of suicide and where to source it, from that site. [REDACTED]	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Dan�s family � East Midlands Ambulance Service � CQC � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) This report is being sent to: Nottinghamshire Healthcare NHS Foundation Trust \| Department of Health and Social Care \| NHS England \| OFCOM
26/11/2024	2024-0654	Jay Whiting	Devon, Plymouth and Torbay	Chief Executive, Plymouth City Council Via email: [REDACTED] (Head of Legal Services and Monitoring Officer, Plymouth City Council � who has been relevant contact through investigation and inquest process)	On 17 January 2023 an investigation was commenced into the death of Jay Stuart Whiting. The investigation concluded at the end of the inquest hearing on 14 November 2024 at Exeter Coroner�s Court, in the County of Devon, Plymouth and Torbay Coroner Area.� A short-form conclusion of �road traffic collision� was determined.	Jay Whiting was only 21 years old when he was fatally injured in a single-vehicle road traffic collision in Plymouth on 7 January 2023. � Following medical evidence heard at the inquest, the cause of death was determined in Section 2 of the Record of Inquest as: � 1a � head injury 1b � road traffic collision � Section 3 of the Record of Inquest (which answered how, when and where Jay Whiting came by his death) was determined as follows: � �Jay Whiting was the sole occupant of a vehicle registered to him when he was driving northbound on Embankment Road, Plymouth, in the early hours on 7 January 2023.� Jay lost control, and was then unable to regain control, of the vehicle, owing to a number of relevant factors, including very wet weather and significant water collection on the road, the poor condition of the vehicle�s rear tyres and the reclined position of the driver�s seat.� Jay�s vehicle left the road and hit a mature tree, which was situated on the pavement adjacent to the carriageway.� The collision of the vehicle with the tree resulted in Jay suffering fatal injuries.� Despite initial resuscitation by attending paramedics and transport to Derriford Hospital, Plymouth, Jay died there in the neuro-intensive care unit later on 7 January 2023.�	COPIES AND PUBLICATION � I have sent a copy of my report to Jay Whiting�s mother and father and Devon and Cornwall Police (via their road casualty reduction officer for Plymouth). � I have also sent a copy of my report to the Chief Coroner. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Road (Highways Safety) related deaths	Plymouth City Council
19/04/2023	2023-0126	Elizabeth Hutchins	Avon	Chief Executive, Royal United Hospital, Bath	On 28 January 2022 I commenced an investigation into the death of Elizabeth Mavis HUTCHINS. The investigation concluded at the end of the inquest . The conclusion of the inquest was � Natural causes contributed to by neglect. The medical cause of death was recorded as: 1a Cardiac arrest 1b Acute coronary syndrome, myocardial infarction 1c Coronary artery atherosclerosis II Type 2 diabetes, hypertension, aortic stenosis	The deceased Elizabeth Mavis HUTCHINS died on 23 January 2022 at Royal United Hospital, Bath. She had been admitted unwell on 11th January 2022 after falling and breaking her arm. She suffered myocardial ischaemia and injury on the night of 13th /14th January which was not treated or managed in any way at all. She was not seen by a doctor again until she suffered a cardiac arrest on 18th January 2022.	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: Royal United Hospital
10/04/2024	2024-0191	Cariss Stone	Somerset	Chief Executive, Somerset Partnership NHS Foundation Trust	On 19th August 2019 an investigation was opened into the death of Cariss Lucy Stone. The investigation concluded at the end of the inquest on 9th April 2024. The conclusion of the inquest was that Cariss Lucy Stone died as a result of 1(a) hypoxic brain injury due to 1\|(b) cardiac arrest due to 1(c) asphyxia due to pressure to the neck. The conclusion of the jury was that �Cariss Lucy Stone died by accident. Deficiencies in the way that she was observed possibly contributed to her death.�	Cariss Lucy Stone was detained under the Mental Health Act on Holford Ward in Taunton, a Psychiatric Intensive Care Unit. While detained she self-harmed including multiple occasions of attaching a ligature around her neck and attempting self- strangulation. She was subject to level two observations, universally referred to on the ward as �five minute observations�. Staff on the ward were confused as to how often Cariss was required to be observed every hour. During an interval in observations Cariss applied a ligature with fatal effect. The healthcare assistant who found Cariss did not have a ligature cutter.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely Cariss� family via their legal team. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Somerset Partnership NHS Foundation Trust
11/06/2024	2024-0315	Deceased name:Juan Martin	Inner West London	Chief Executive, South West London and St George�s Mental Health NHS Trust NHS South West London Integrated Care Board The Rt Hon Victoria Atkins MP, Secretary of State for Health and Social Care	On 24 April 2022 an investigation commenced into the death of Juan David Martin. The investigation concluded at the end of the inquest on 10 June 2024. The conclusion of the jury was suicide.	Juan Martin was diagnosed with emotionally unstable personality disorder, depression, and anxiety. He was known to have suicidal ideation and had in the past attempted suicide. On 6 April 2022 he was detained by police under s.136 of the Mental Health Act 1983 at Beachy Head, Brighton having expressed a desire to cause harm to himself; he was taken to a place of safety. On 7 April 2022 he was informally held at the Lotus Assessment Suite at Springfield Hospital, London. On 10 April 2022 he expressed a desire to leave the Lotus Assessment Suite. He was then assessed under the Mental Health Act 1983 on 11 April 2022, and subsequently liable to be detained under s.2 of the Mental Health Act 1983, pending an appropriate bed. Accordingly, Juan Martin remained at the Lotus Assessment Suite held under common law. On 12 April 2022 he was seen by staff squeezing through a door leading to the external door of the unit; he was challenged by staff, who persuaded him to return. At approximately 15:00 on 12 April 2022 a bed became available on Ward 2 but was contingent upon another patient transferring out. This did not happen. According to witnesses at approximately 17:00 a bed became available on the Jupiter ward. There is no documentary evidence confirming this. By 19:03 the fire alarm was activating on the Lotus Assessment Suite triggered by steam from a shower. There was no fire evacuation policy for those liable to be detained and accordingly Juan Martin was evacuated along with other patients to an insecure area outside the Lotus Assessment Suite. He immediately ran off and was visible on CCTV in the vicinity of the hospital for approximately up to 8 minutes after. At 01:40 on 13 April his bank card was used to make a balance enquiry followed by a cash withdrawal of �11.99. At 11:25 on 13 April 2022 members of the public reported seeing a male on the wrong side of the fence [REDACTED]. Local police officers attended and at 11:57 he was witnessed by police officers allowing himself to fall. Despite emergency life support provided by officers on scene, an off- duty Emergency Department doctor and paramedics Juan Martin was confirmed deceased at 12:36. The medical cause of death was: 1a. Multiple Injuries; and 1b. Impact after descent from height.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Juan Martin�s family. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) \| Mental Health related deaths This report is being sent to: South West London and St George�s Mental Health NHS Trust \| NHS South West London Integrated Care Board \| Department of Health and Social Care
15/03/2024	2024-0148	Sarah Sutherland	Surrey	Chief Executive, UK Council of Psychotherapy President Royal College of Psychiatrists Chief Executive NHS England Chief Executive CQC Brainwaves	On 17th December 2023 I resumed an investigation into the death of Sarah Louise Sutherland. On 17th January 2024, the investigation was concluded: � The medical cause of death given was: � 1a. Suspension � I recorded the following in Box 3 of the Record of Inquest: � � Sarah Louise Sutherland had significant mental health challenges with an ongoing history of suicidal ideation and self-harm. On the 17th December 2022, Ms Sutherland was found to have died by intention through self-suspension at her home address in Redhill having last been known to be alive on the 15th December 2022. � I concluded Ms Sutherland died by way of Suicide	CORONER�S CONCERNS Guidelines for regulation and management of private psychotherapists The psychotherapist did not fulfil the UKCP (of which she is a member) Code of Ethics and Professional Practice by failing to keep any clinical records in the care she provided to Ms Sutherland, nor has her practiced changed since Ms Sutherland�s death. � The psychotherapist did not at any time undertake risk assessments and blurred if not crossed the boundary of a therapeutic relationship between a therapist and a client. � Proactive need for co-ordination of NHS mental Health services and Private Psychotherapy � Following Ms Sutherland�s death, Surrey and Borders NHS Foundation Trust have, as long as client consent is obtained, introduced a �standard process for communication with private providers of psychological therapies�. However, there is a national lack of co-ordination of treatment and communication between NHS and private providers of mental health care with no formal or informal mechanism or processes in place to liaise with each other to ensure the best mental health care and safety of their clients.	Signed: Dr Karen Henderson DATED this 15th March 2024	Suicide (from 2015) This report is being sent to: Council of Psychotherapy \| Royal College of Psychiatrists \| NHS England \| Care Quality Commission \| Brainwaves
08/09/2023	2023-0324	Cherry Garland	Avon	Chief Executive, University Hospitals Bristol and Weston NHS Foundation Trust (�UHBW�)	On 31 October 2022 an investigation commenced into the death of Ms Cherry Lynne GARLAND, aged 77. The investigation concluded, at the end of a 2-day inquest, on 17 August 2023. � The medical cause of death was: � 1a)�� Sepsis and Right sided heart failure 1b)�� Coronary artery atheroma (operated) 2)�� Chronic Lymphocytic leukaemia � The narrative conclusion of the inquest was as follows: � Cherry Garland was 74 years old and had a background of known heart problems and Chronic Lymphocytic Leukaemia when she underwent a percutaneous procedure to examine and stent her coronary arteries. Unfortunately one of her arteries perforated during the procedure and she required emergency open-heart surgery. The surgery was successful, but she suffered vascular injury from the presence of an arterial sheath, and went on to develop Covid. She then developed pneumonia, which in turn triggered sepsis, and sadly she died on 11 October 2022, in the Bristol Royal Infirmary, as result of both sepsis and right-sided heart failure.	It is not necessary to give more detail about the circumstances of death in this case, because the issue I am addressing in this report did not contribute to Ms GARLAND�s death � it was �incidental� to her death, but still extremely important.	I have sent a copy of my report to the Chief Coroner and to the family of the deceased. I have also sent it to the Care Quality Commission who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: University Hospitals Bristol \| Weston NHS Foundation Trust
20/04/2023	2023-0131	Jodie McCann	Nottinghamshire	Chief Executive, University Hospitals of Derby and Burton NHS Foundation Trust	On the 2nd April 2022, I commenced an investigation into the death of Jodie Catherine McCann. The investigation concluded at the end of the inquest on the 19th April 2023 � The conclusion of the inquest was a Narrative as follows: � Jodie died on the 2nd April 2022 at Queens Hospital, Burton-on- Trent, following a prolonged cardiac arrest, caused by a lack of oxygen, as the trachea could not be re- intubated following the sudden displacement of her tracheostomy tube. Jodie required the tracheostomy tube to provide ventilation to her lungs, as she had developed multi organ failure following an earlier cardiac arrest of at least 17 minutes at Kings Mill Hospital on 18.3.22. This first arrest at Kings Mill Hospital was sudden and unpredictable, likely caused by airway obstruction, from a combination of opiates affecting her breathing, her high BMI, and the pain and stress of gallstone pancreatitis which required strong opiate medication. Undertreated Hypothyroidism also likely made a more than minimal contribution to this first arrest. Jodie was making a reasonable recovery from the first arrest, with improving neurology and reducing ventilatory requirements. She was transferred to Burton Hospital on 22.3.22 for further critical care management. There she continued to improve, but required continuing ventilation. A tracheostomy tube to aid weaning from ventilation was inserted on 31.3.22. There was no individualised planning for the possibility of tracheostomy displacement , which was a known risk, with no plan to ensure the correct equipment was available, and no plan to ensure senior help was available as quickly as possible, should the tracheostomy tube become displaced. These serious issues of care at Burton Hospital, on a balance of probability, made a more than minimal contribution to Jodie�s death.	Jodie was a previously fit and well young woman aged twenty two. She developed gallstone pancreatitis requiring admission to Kings Mill Hospital on 16.3.22. She had a cardiac arrest on the ward at KMH on 18.3.22, and as a consequence developed multi organ failure, requiring Critical Care treatment. She had a period of care at KMH CCU, but had to be transferred to Burton Hospital on 22.3.22 as KMH CCU was at operational capacity. She continued to make good progress on the CCU at Burton Hospital, but there were continuing issues of difficult airway management. Jodie had a tracheostomy tube placed on 31.3.22, which became displaced early morning on 2.4.22. This could not be replaced, nor another airway achieved. She died from a further prolonged cardiac arrest as a consequence of this final hypoxic event. � The Determination dated 19.4.23 gives detailed findings as to the circumstances of Jodie�s death, and is appended to this report.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1.�� Jodie�s family � 2.�� Sherwood Forest Hospitals NHS Foundation Trust � 3.��[REDACTED] , Consultant in Critical Care Medicine and Anaesthesia, UHDBT � 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: Derby and Burton NHS Foundation Trust
19/04/2023	2023-0125	David Mason	Worcestershire	Chief Executive, Worcestershire Acute Hospitals NHS Trust (WAHT) Chief Executive, West Midlands Ambulance Service University NHS Foundation Trust (WMAS) Executive Officer, Association of Ambulance Chief Executives (AACE) Chief Executive, National Institute for Health and Care Excellence (NICE) Chair, Clinical Committee, Society for Endocrinology Chief Executive, NHS England	On 13 March 2022 an investigation was commenced into the death of David Ernest Mason. The investigation concluded at the end of the inquest hearing on 12 April 2023 at Stourport Coroner�s Court, in the Worcestershire Coroner Area. The conclusion (a �narrative� conclusion in Box 4 of the Record of Inquest) was determined as follows: �David Mason died as a result of an acute adrenal crisis, caused by Addison�s disease and precipitated by the trauma of a fall and fractured hip. Insufficient administration of steroid medication by medical professionals was a contributory factor in David�s death.�	David Mason was an 82-year-old gentleman with significant medical co-morbidities, including a known diagnosis of Addison�s disease. By March 2022, Mr Mason was becoming more frail and, owing to mobility issues, was suffering from recurrent falls. Mr Mason fell in his bedroom on the evening of 5 March 2022. An ambulance was called but it took a number of hours until paramedics arrived and transported Mr Mason to hospital. Once there, Mr Mason was diagnosed with a fractured hip, as a result of the trauma suffered when he fell. Mr Mason did not present as acutely medically unwell (as opposed to him having an obvious requirement for trauma assessment, followed by surgery) at any time after the fall or whilst in hospital and no clinician involved in his care appreciated that, without additional steroid medication, he was at high risk of developing an acute adrenal crisis, owing to his primary adrenal insufficiency (Addison�s disease) and the trauma and physiological stress that he had suffered following the fall. In the early hours of 7 March 2022, whilst in a bed on a surgical trauma ward, Mr Mason was found breathing abnormally and was obviously acutely unwell. Mr Mason went into cardiac arrest shortly after and died. Mr Mason had suffered an acute adrenal crisis, which was the cause of his sudden and unexpected deterioration and death. � Following medical evidence heard at the inquest, the cause of death was determined as: � 1a � acute adrenal crisis (on a background of a known diagnosis of Addison�s disease) 1b � fractured neck of femur following a fall 2 � frailty � Box 3 of the Record of Inquest (which answered how, when and where Mr Mason came by his death) was determined as: � �David Mason had been unwell for a number of years, including suffering from primary steroid insuffiency (Addison�s Disease), a condition which required the administration of replacement steroid medication. Owing to significant frailty, David had fallen over at home in the evening of 5 March 2022, suffering a fractured hip (diagnosed in hospital on 6 May 2022, following x-ray). An ambulance was not available for a number of hours owing to demand and resource factors, however paramedics attended on David at home and conveyed him to hospital early in the morning on 6 March 2022. No required additional steroid replacement therapy was administered to David by paramedics. In hospital, no required additional steroid replacement therapy was administered to David by clinicians over a period of approximately 19 hours, which led to David�s sudden deterioration and death in the early hours of 7 March 2022 at the Worcestershire Royal Hospital.�	I have sent a copy of my report to the family of David Mason and the Chief Coroner. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Worcestershire Acute Hospitals NHS Trust \| West Midlands Ambulance Service University NHS Foundation Trust \| Association of Ambulance Chief Executives \| National Institute for Health and Care Excellence \| Clinical Committee \| NHS England
13/06/2024	2024-0317	Graham Faulkner	Cheshire	Chief executive � Health and Safety Executive	On 03 April 2019 I commenced an investigation into the death of Graham FAULKNER aged 64. The investigation concluded at the end of the inquest on 31 May 2024. The conclusion of the inquest was that: � �Mr Faulkner died as a result of medical complications arising from an accident at work some years previously. This was contributed to by failures in the administration and management of the Permit to Work process and a lack of challenge, at all levels, around the use of PPE.�	In October 2015 Mr Faulkner was exposed to caustic soda at work. Mr Faulkner was hospitalised approximately week later, in a serious condition. Within a month, his paraplegia had started. He was not discharged from hospital until 2017. � He died in 2019 from the sequalae of his original injury ie exposure to caustic soda.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Mr Faulkner�s family Industrial Chemicals Ltd (�ICL�) 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.	Accident at Work and Health and Safety related deaths This report is being sent to: Health and Safety Executive
24/08/2023	2023-0307	Jonathan Mann and Margaret Costa	Somerset	Civil Aviation Authority of Canary Wharf London E14 4HD. � Military Aviation Authority of Regulatory Publications Team #5102 Level 1 Juniper Building MOD Abbey Wood (North) Bristol BS34 8QW United Kingdom	On the 16th September 2021, my predecessor, Mr Tony Williams, commenced an investigation into the deaths of Jonathan Paul Bost Mann, aged 69 and Margaret Jean Costa, aged 74. � The investigation concluded at the end of the inquest on 22nd August 2023. The conclusion of the inquest was: Jonathan Paul Bost Mann�s death was recorded as a death by Misadventure, with the medical cause of his death being given as: Ia) Multiple Injuries � Margaret Jean Costa�s death was recorded as an Accidental Death, with the medical cause of her death being given as: Ia) Multiple Injuries � Mr Mann and Mrs Costa died within the same incident and so their inquests were heard together.	Mr Mann had held his pilot�s licence since 2000. He had owned his plane, a Cap- 10-B since 2014. He had a current and valid private pilot�s licence which permitted him to fly under Visual Flight Rules (�VFR�). Mr Mann did not possess the skills, experience of ability to fly in cloud; he could only fly in clear skies as he was unable to �instrument fly� and could only fly by reference to what he could see out of the window. � His passenger on the day, Mrs Costa, had no flying experience and did not possess a pilot�s licence. She had no active part in the events that unfolded. � On 12th August 2021 at 08:04 Mr Mann took off from Watchford Farm, Yarcombe near Taunton, Somerset with Mrs Costa on a planned pleasure trip for the day to the Isle of Sicily. There was no evidence that Mr Mann had used recognised aviation sources to check the weather prior to departure, instead obtaining weather information from news weather-based apps. � At around 09:10 the weather conditions deteriorated and so Mr Mann turned back. At around 10:10 found himself at an altitude of 7,500ft flying above cloud, He was not qualified to fly through cloud. He contacted the Distress and Diversion Cell (�D&D Cell�) on the emergency frequency for assistance. � Mr Mann began to descend to a lower altitude but he appears to have become spatially disorientated due to the extreme stress of flying in the weather conditions in which he found himself and when he emerged from cloud, the ground was not where he expected it to be. The plane collided with a large oak tree at Lower Colley Farm, Buckland St Mary near Chard, Somerset and was destroyed on impact with both the pilot and passenger being thrown from the wreckage and suffering catastrophic injuries that were incompatible with life.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (i)��[REDACTED] (on behalf of the Mann Family) (ii)��[REDACTED] (on behalf of the Costa Family) (iii)�[REDACTED] The Air Accident Investigation Bureau (AAIB) � 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: Civil Aviation Authority \| Military Aviation Authority
16/06/2023	2023-0196	Christine Cumbers	Essex	Clacton Community Practices Kennedy Way Medical Centre Kennedy Way Clacton � on � Sea CO15 4AB	On 10 May 2022 I commenced an investigation into the death of Christine Margaret Cumbers. The investigation concluded at the end of the inquest on 19 May 2023. � The conclusion of the inquest was a narrative conclusion: � Christine Margaret Cumbers suffered with Hyperthyroidism and was admitted to hospital with a skin rash eruption secondary to Carbimazole use, a rare but recognised complication of this necessary Hyperthyroidism first line medical treatment. She developed sepsis during her hospital admission which was belatedly diagnosed and treated due to lack of continuity care caused by multiple ward moves. The belated diagnosis and treatment of sepsis more than minimally contributed to her death on 22 April 2022 at Colchester General Hospital, Essex.	Christine Margaret CUMBERS was born on 3 September 1948 and at the time of her death on 22 April 2022 she lived in Clacton-on-Sea, Essex. Mrs Cumbers was known to have Hyperthyroidism, Hypertension, Osteoarthritis, Hypercholesterolaemia and a stable Angina. � On 29 March 2022, Mrs CUMBERS was admitted to Colchester Hospital, having presented with skin eruption following use of Carbimazole, prescribed for an overactive Thyroid, by her GP at above named Practice. � Mrs Cumbers suffered an allergic reaction to the prescribed Carbimazole, she stopped Carbimazole and reported it to the GP practice on 21 March. � She was seen by a GP on 22 March in person, on 24 March there was a failed home visit with no follow up call directly to Mrs Cumbers, on 25 March there was a consultation via telephone, on 28 March she spoke to reception and later a nurse over the telephone and on 29 March she was seen at home. � The GP Practice carried out an internal review of the incident, including the consultations conducted by the various GPs and other clinical staff and produced a �Significant Event Analysis� report. This report was admitted as evidence as part of the coronial investigation and identified that a clinician should have followed up on the failed encounter and the consultation on 28 March did not meet the required standards and the management of the care was found to be wrong, leading to a delay in administration of antibiotics and hospital admission. The evidence showed that this event did not cause or contributed to the death on the balance of probabilities. � However, the Practice confirmed in evidence that no actions have been taken to embed the learnings identified in the Significant Event Analysis report, to ensure the appropriate standards are upheld by the Practice�s clinical staff when carrying out consultations and providing treatment.	I have sent a copy of my report to the following. � ?�� Mrs Cumbers� family ?�� The 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.	Other related deaths This report is being sent to: Clacton Community Practices
27/06/2024	2024-0344	Paul Holmes	Cornwall and the Isles of Scilly	Cornwall Partnership NHS Foundation Trust � Royal Cornwall Hospitals NHS Trust	On 14 June 2022 I commenced an investigation into the death of Paul Byron Holmes who died on 29 May 2022 then aged 90. The investigation concluded at the end of the inquest on 22 February 2024. The cause of death was lower respiratory tract infection following a period of terminal decline on a background of delirium, frailty of old age, ketoacidosis, poor oral intake/nutrition, type 2 diabetes mellitus, chronic kidney disease and fractured ribs and sternum. I recorded that Paul Byron Holmes was pronounced deceased at 0645 on 29 May 2022 at Arbour Cottage, Mount Hawke, Truro. Paul died as a result of complications including dementia and a chest infection arising from chest injuries sustained in a road traffic collision on 4 April 2022 and subsequent hospitalisation and loss of mobility against a background of frailty. I recorded a conclusion of road traffic collision.	CIRCUMSTANCES OF DEATH On 4 April 2022 Paul was a passenger in a vehicle involved in a road traffic collision as a result of which he sustained chest injuries comprising fractured ribs and a fractured sternum. Paul was admitted to the emergency department of the Royal Cornwall Hospital Truro the same day for treatment of his injuries. Although Paul was initially lucid, over the subsequent few days he developed delirium which was probably due to a combination of the trauma, his age and frailty, the painkilling medication and disorientation being in a busy acute hospital. On the evening of the 16 April 2022 Paul was transferred from the Royal Cornwall Hospital to Liskeard Community Hospital. Paul�s medical condition had stabilised and it was felt that a community hospital was the best location for rehabilitation and for his delirium to settle. The clinician with care of Paul felt that his prognosis was guarded although that was not communicated to Paul�s family. Unfortunately Paul�s condition deteriorated on 17 April 2022. The nursing staff had difficulty encouraging Paul to eat and hydrate, his heartrate and rate of breathing had increased. Those treating him felt that Paul was suffering from an infection. A decision was taken to transfer Paul back to the Royal Cornwall Hospital which took place in the early hours of 18 April 2022. At the Royal Cornwall Hospital Paul was given Intravenous antibiotics and fluids. It was felt that Paul did not have an infection and that the principal issue was dehydration. By late morning on 18 April 2022 clinical staff considered that his condition had stabilised and he could be transferred back to Liskeard albeit that his dehydration had not resolved and intravenous fluids needed to be continued. Because of Paul�s ongoing dehydration and overall frailty there needed to be a robust and detailed handover between treating doctors from the two hospitals as to the ongoing treatment plan and what to do in the event of Paul deteriorating. This did not take place. There was a nurse to nurse handover without sufficient details being exchanged or recorded, particularly with regard to the unresolved dehydration. There was also an error in the date of the prescription for the intravenous fluids which resulted in a delay to Paul receiving fluids. Paul�s condition deteriorated again resulting in him being transferred back to the Royal Cornwall Hospital at 18.45 the same day where he received appropriate treatment for dehydration and a possible infection. Unfortunately whilst Paul�s condition stabilised his delirium persisted and it was felt that he should return home for palliative care. Paul returned home on 16 May where he died on 29 May 2022. The planning and handover for Paul�s transfer between the Royal Cornwall Hospital and Liskeard Community Hospital at around midday on 18 April 2022 was inadequate and caused significant discomfort and distress to Paul and a delay to the treatment of the dehydration. It did not however cause or contribute to Paul�s death over a month later.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons �[REDACTED], � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Road (Highways Safety) related deaths This report is being sent to: Cornwall Partnership NHS Foundation Trust \| Royal Cornwall Hospitals NHS Trust
16/10/2024	2024-0563	Phyllis Hart	Staffordshire	County Hospital Stafford; Chief Coroner; and Family of the deceased.	On the 17th April 2023 2023, I commenced an investigation into the death of Mrs Hart.� The investigation concluded at the end of the inquest on 16 October 2024. �The conclusion of the inquest was a conclusion of natural causes.� � The cause of death was: � � 1a) Sepsis, 1b) Acute Limb Ischaemia 1c) Peripheral vascular disease II) Diabetes mellitus	i) Mrs Hart was admitted to the County Hospital in Stafford on the 19 March 2023.� On the 21 Marc 2023 she started to show signs of having a ischaemic leg.� On the 27th march vascular specialist review was requested.� There is no vascular team located on the County Hospital, so the review was delayed for 4 days until the Vascular Consultant was next at the County Hospital.� ii) At the review, the decision was made that Mrs Hart was for palliative care only.� She passed away on the 8 April 2023	I have sent a copy of my report to the County Hospital in Staffordshire and the family of Phyllis Christina Hart.� I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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	County Hospital Stafford
08/02/2024	2024-0073	Thomas Godderidge	Cumbria	Cumberland Council Adult Social Care	On 3 March 2023 I commenced an investigation into the� death� of� Thomas� GODDERIDGE. The investigation concluded at the end of the inquest. The conclusion of the inquest was: � Accidental death. � 1a) Smoke Inhalation in combination with Chronic Obstructive Pulmonary Disease and Ischaemic Heart Disease	Thomas Godderidge was 85 years old. He lived at [REDACTED], �Carlisle. Mr Godderidge was frail and suffered from short-term memory loss. On 16th February 2023 a fire broke out at Mr Godderidge�s home. He died as a result of smoke inhalation. Prior to Mr Godderidge�s death repeated concerns had been raised about his risk of causing a fire. He repeatedly discarded lit cigarettes and had the habit of cutting paper into strips, which provided a ready source of fuel for a fire.	I have sent a copy of my report to the Chief Coroner and to the family of Mr Godderidge and [REDACTED] of Beacon Care. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Cumberland Council Adult Social Care
01/05/2024	2024-0234	Harry Hall	Northumberland	Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust	On 1 June 2023 I commenced an investigation into the death of Harry David HALL. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was Suicide � 1a Intracranial Bleed	Harry David Hall had a history of depression, mental health illness and had expressed recent suicidal ideation. In the period leading up to his death he had been researching various websites relating to suicide. He was under the care of the West Northumberland Community Treatment Team and no in person assessment had taken place prior to his death. � At approximately 16.30 hours on 29 May 2023 in the rear garden of Croydon Cottage Thorngrafton Hexham Northumberland he was found with a self-inflicted traumatic head injury the result of the firing of a captive bolt gun that he had recently purchased.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Hall�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.	Mental Health related deaths This report is being sent to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
29/02/2024	2024-0259	Christopher Vickers	Gateshead and South Tyneside	Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW)South Tyneside Council	On 20/07/21 an investigation was commenced into the death of Christopher Paul Vickers. The investigation concluded at the end of the inquest on 29/02/24. � The conclusion of the inquest was: � The Deceased, who suffered a worsening of symptoms in respect of his mental health conditions and ADHD, ended his life during an acute on chronic episode. � The medical cause of death was: 1a) Pressure on the neck from a ligature	The Deceased had received assessment and treatment from primary and secondary care in relation to his mental health conditions and ADHD and had been assessed by the local authority in early 2020 and found to have specific needs. � From the end of 2020 there was a worsening of the deceased�s symptoms and behaviours. The deceased reported that the impact of the COVID-19 pandemic had affected his mental health and ADHD and was a factor in exacerbating his symptoms of anxiety and intrusive thoughts. From June 2021 there was a further escalation of the Deceased�s behaviours and risks of self-harm and harm to others, resulting in an increase in referrals and contacts to agencies by the Deceased�s family and other professionals for support, assessment, and treatment. � The Deceased underwent triage and full assessments by the crisis team and a review by the ADHD team, which ultimately resulted in a referral to and assessment by the community treatment team, who agreed to provide treatment on 25/06/21 and the Deceased was placed on their waiting list. The Deceased was prescribed medication to address anxiety and lack of sleep. � Despite the known escalation of behaviours, the increase in the risks to self and to others, and the fact that the Deceased was open to various agencies and services, there were multiple repeated missed opportunities by different organisations to instigate a safeguarding referral for formal safeguarding supervision, or to convene a or multi-disciplinary or multi-agency meeting to co-ordinate the Deceased�s care with the provision of a shared care plan. � The Deceased was found on 18/07/21 with a ligature around his neck and death was certified on 18/07/21 at 18.06.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the Family of Mr Vickers and Marsden Road Health 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.	Mental Health related deaths This report is being sent to: South Tyneside Council \| Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
04/03/2024	2024-0123	Sarah Keen	Mid Kent and Medway	DARTFORD AND GRAVESHAM NHS TRUST KENT AND MEDWAY NHS AND SOCIAL CARE PARTNERSHIP TRUST	On 30th June 2023 I commenced an investigation into the death of Sarah Rhiannon� Keen aged 32. The investigation concluded at the end of the inquest on 29th February 2024. The conclusion of the inquest was that Sarah Keen died as the result of an accident from the combined effect of ingesting fluoxetine and dihydrocodeine in the presence of cocaine.	Sarah Keen had spent much of her young life in secure hospitals following a diagnosis of emotionally unstable personality disorder. She was both a risk to herself and others on occasion. In 2022 she was transferred to the Medway mental health team and was moved into supported accommodation as it was clear that she was not deriving much benefit from long hospital admissions. She required assistance with most activities of daily living including managing her medications. On the 17th April 2023 she was arrested [REDACTED] . She was described as intoxicated and having taken a number of gabapentin tablets. She was conveyed to Darent Valley Hospital when she was de-arrested and admitted for medical treatment, it having been established that she was anaemic. She received a blood transfusion. Over the course of the admission she made multiple attempts to leave the hospital, on one occasion shouting that she was going to kill herself [REDACTED]. Sarah was seen by psychiatric liaison nurses on 18th April 2023 who determined the risk of self harm to be high and recommended that she be provided with 1:1 care. A deprivation of liberty order was put in place to ensure that she received medical treatment. On 19th April 2023 she was seen by a psychiatrist at which point she was discharged back to the community mental health team, an action plan with coping strategies full future trigger points was sent to her community team and a note was placed by the psychiatrist in the medical records to indicate the above but also that further DSH was likely- 1 to 1 recommended. On the evening of 19th April 2023 Sarah was discharged from the hospital and returned to her supported accommodation accompanied by a member of the hospital�s enhanced care team who left at the point of her arriving at the address. She had been discharged with seven days of medication. The enhanced carer was carrying one of Sarah�s bags which she gave to the support worker who answered the door. Sarah stayed up for much of the night and the following morning indicated to the support worker that she wanted to go to sleep and shouldn�t be woken. She was checked at her medication times but left asleep at which time she was snoring. She was checked again in the evening and was found to have died. A post mortem examination determined the medical cause of death to be multi drug toxicity she having taken near fatal levels off fluoxetine and dihydrocodeine in the presence of cocaine.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Sarah Keen, Dartford & Gravesham NHS Trust, and Kent & Medway NHS and Social Care Partnership 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 This report is being sent to: Dartford and Gravesham NHS Trust \| Kent and Medway NHS and Social Care Partnership Trust
06/11/2023	2023-0429	Kevin Gale	Cumbria	DEPARTMENT FOR WORK AND PENSIONS (for the attention of the Rt Hon Mel Stride MP, Secretary of State for Work and Pensions)	Mr Kevin Conrad GALE died on 4 March 2022 at his home address. � An inquest into Mr Gale�s death was opened on 22 March 2022 and his inquest was heard before me on 2 November 2023. � The medical cause of Mr Gale�s death was: � 1a Hanging � The determination was: � Mr Kevin Conrad Gale died on 4 March 2022 at his home address, 8 Langton Court, Penrith as the result of deliberate self-suspension [REDACTED] . Mr Gale had a long history of low mood and anxiety. He was engaging with mental health services and had been diagnosed with severe depression and anxiety. Mr Gale was taking his medication but was still struggling to manage anxiety. Although Mr Gale denied suicidal intent, on the evidence and on the balance of probabilities, Mr Gale intended to take his life. The conclusion of the inquest was: Suicide	Mr Gale was detained under Section 2 Mental Health Act in November 2021 and was discharged from that section on 4 January 2022. Mr Gale was diagnosed with severe depression and anxiety. Mr Gale was seen regularly by mental health professionals and was in frequent contact with mental health services. Those services were provided by Cumbria, Northumberland Tyne & Wear NHS Foundation Trust (�the Trust�). Mr Gale was compliant with his medication and engaged with services. He was well supported by his family and friends. � Mr Gale�s anxiety continued during his engagement with mental health services. Evidence was heard about what caused Mr Gale�s anxiety. One ongoing feature was his application for Universal Credit. � On 2 March 2023, 2 days before his death, Mr Gale was seen by an Associate Specialist Psychiatrist, who gave evidence at the inquest. The Psychiatrist considered Mr Gale�s anxiety was exacerbated by his application for Universal Credit. During Mr Gale�s appointment, the Psychiatrist called the benefits office for help but the call was not answered before the end of the consultation. Mr Gale was expecting a call from a DWP representative the next day (3 March). � On 3 March 2022 at approximately 11:00 am, Mr Gale spoke to the duty Registered Mental Health Nurse. He remained very anxious and his main concern was the application for Universal Credit. � During their evidence, the Associate Specialist Psychiatrist expressed concerns about the experience of mental health service users with DWP. These concerns were not just specific to Mr Gale. � Evidence was also given by the Trust�s Group Nurse Director (a Registered Mental Health Nurse) who considered that the issues identified by the Psychiatrist were national. The Director considered it important to address these issues as they were debilitating for service users. � The Director advised that the Trust�s Crisis Team had started a food bank 3 years ago to support service users. The Director was also aware that the DWP had been invited to the Cumbria Suicide Prevention Group. � I stress that I did not make a causal link between Mr Gale�s death and his anxiety about his Universal Credit application. DWP was not an Interested Person in Mr Gale�s inquest and did not give evidence as the concerns raised did not come to light until the hearing.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Mr Gale�s family. Cumbria, Northumberland Tyne & Wear NHS Foundation Trust I have also sent copies to: Lakes Medical Group (Mr Gale�s GP surgery) � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) This report is being sent to: Department for Work and Pensions
16/10/2024	2024-0557	Christiana Dawson	South Yorkshire (West)	Darnell Grange Nursing Home 84 Poole Rd �� Darnall �� Sheffield �� S9 4JQ.	On 24 June 2024 I commenced an investigation into the death of Christiana Betty Dawson, known as Betty, aged 94. The investigation concluded at the end of the� inquest on 10 October 2024. The conclusion of the inquest was a narrative� conclusion as follows:� Christiana Betty Dawson fell at least ten times whilst a resident at Darnell Grange� Care Home in Sheffield. On 16 March 2024 she fell and was moved into her bed by� carers. Paramedics attended and identified a fractured left neck of femur. It cannot be said whether the fracture was caused by the fall or her being moved.� She underwent surgery to repair the fracture on 18 March 2024 and died on 19 March 2024 at the Northern General Hospital in Sheffield as a result of the fracture and her frailty.� Her falls risk assessments and care plans were reviewed after each fall, but no� changes were made. An application to place her into nursing care was declined� despite her increasing frailty and risk. Had further fall prevention measures been put in place, and had nursing care been provided, her falls may have been prevented	Betty was admitted to Darnell Grange on 5 May 2020. She mobilised with a Zimmer frame and was a high risk of falls. Her falls risk was initially managed with an ultra-low-profile bed. A sensor mat was later put in place, but it is not known when.� There was no available evidence about any falls prior to 30 March 2022. She fell, unwitnessed, on 30 March 2022, 23 May 2022, 23 September 2022 and 23 July 2023.� As a result of the fall on 23 July she sustained a right orbital fracture. She fell again, unwitnessed, on 9 September 2023 and was admitted to hospital. The Court heard Darnell Grange felt they could not accommodate her within their� residential unit any longer and a nursing placement was required. The funding for this� was declined and Darnell Grange accepted her back onto their residential unit despite accepting they could not manage her falls risk.� She fell again on 30 September 2023 and 16 December 2023. On 24 January 2024 her anti-coagulation medication was stopped by her General� Practitioner due to her frequent falls. Darnell Grange continued to administer the� medication until her fall on 13 February 2024 when concerns were raised about this by attending paramedics.� She fell again on 13 February 2024 and twice on 16 March 2024. All but one of those falls was unwitnessed.� On 16 March 2024 she sustained an osteoporotic fractured neck of femur. After the second fall that day, was moved into her bed by staff. It cannot be said whether the fracture was caused by the fall or by Betty being moved after the fall.� She underwent a nailing of the right femur on 18 March 2024 and died in hospital on 19 March 2024 with a cause of death provided as: 1a. Osteoporotic fracture of right neck of femur (operated) and frailty of old age. 2. Vascular dementia and heart failure. After every fall her care plan and falls risk assessment were reviewed and no changes made.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� i. Betty�s family. ii. Care Quality Commission, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make 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	Darnell Grange Nursing Home
06/12/2024	2024-0676	David Stables	South Yorkshire West	Dearne Valley Group Practice	On 28 March 2024 I commenced an investigation into the death of David� Stables. The investigation concluded at the end of the inquest on 4 December 2024. The conclusion of the inquest was� Suicide 1a Bilateral transection of the ulnar arteries 1b Incised wounds to the wrists	David Stables had a history of mental health issues and had taken two drug overdoses in 2020. He was prescribed sertraline in April 2020 and weaned� himself off this in 2023. His last prescription was issued in July 2023.� David attended many appointments at his GP practice from 2020 to 2023� regarding other issues unrelated to his mental health. In most of these� encounters there is no record of any discussions regarding his mental health.� Whilst he received repeat prescriptions for his sertraline, there is no recorded� entry of a review of his mental health or appropriateness of the medication. It�is noted that he had reduced this himself yet there is no recorded entry of a full review of his mental health at this time. �� I am concerned that there were no recorded mental health or medication� reviews from April 2020 until February 2024 when David attended the GP� asking for help. I was unable to establish whether these reviews had taken� place and just not been recorded or whether full mental health reviews had not taken place when they should have been.� In February 2024 he attended the GP surgery and had a face to face� appointment regarding his mental health. He had anxiety and had difficulties in sleeping and poor appetite. A shared decision was undertaken to put David�on mirtazapine at 15mg and to follow up in 4 weeks time. I was informed that� this was considered because of its side effects of sedation and increased� appetite. A full mental state examination was undertaken which did not identify any Self harm or suicidal concerns.� On 18 March 2024 he was seen again by the GP and there was some� improvement. I was told that self harm and suicidal ideation were specifically discussed and they were strongly denied at both appointments.� There was no concern from the GP when he called 2 days later to ask to� increase his medication although it was accepted that had she known he had� tried to contact the GP surgery on 5th 14 and 15th March then this may have� changed her management in terms of obtaining more information either by� reception or by another appointment. However, I do find that whilst he may� have attempted to contact the GP it cannot be ascertained if these calls� actually made it through to the reception team. I find that there is no evidence to say that this would have changed the management in terms of the� medication although it may have been considered. Further there is evidence� that even if medication had been increased it could have taken up to 4 � 6� weeks to show any benefit. �� David had been given all relevant safety netting advice for a crisis and this was provided verbally and by text message.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: �� Family � [REDACTED] I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or� summary form. He may send a copy of this report to any person who he� believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication� of your response by the Chief Coroner.	�Suicide (from 2015) \| Mental Health related deaths \| Community health care and emergency services related deaths	Dearne Valley Group Practice
19/06/2024	2024-0335	Maureen Woollen	South Yorkshire West	Deerlands Residential Home, 48 Margetson Road, Parson Cross, Sheffield S5 9LS.	On 6 November 2023 I commenced an investigation into the death of Maureen Alison Woollen. The investigation concluded at the end of the inquest on 18 June 2024.	Maureen Alison Woollen (born 24 September 1931) was discharged from the Northern General Hospital in Sheffield to Deerlands Residential Home in Sheffield on 2 October 2023. � The S2A assessment identified she was a high risk of falls due to her underlying dementia and psychosis, her frailty, her limited mobility, the side effects of her medication and her previous falls. � On admission to Deerlands residential home a falls risk assessment was not conducted. � On 3 October 2023 Mrs Woollen was heard shouting and was found on the floor in her room. She could not say how she came to be on the floor. Staff did not identify any external injuries and did not seek medical assistance. � On 6 October 2023 a carer noticed a �fresh big bruise and a lump on her right forehead and temple�. A team leader was notified and decided to call an emergency care practitioner. This call was not made. � Between 6 October 2023 and 13 October 2023 there are no references to Mrs Woollen�s facial injury in the care notes. � On 11 October 2023 staff noticed a decrease in Mrs Woollen�s food and drink intake. This was not recorded in the care notes and medical assistance was not sought. On 13 October 2023 a general practitioner was contacted due to concerns from Mrs Woollen�s family and Deerlands Residential home that Mrs Woollen had experienced a recurrence of psychotic symptoms over the previous two days. � A general practitioner attended on 13 October 2023 and found Mrs Woollen to be �slumped in a chair�. He was told the facial bruising occurred on 9 or 10 October 2023. There are no incidents recorded in the care notes on those dates. � Mrs Woollen was admitted to Northern General Hospital in Sheffield on 13 October 2023 and diagnosed with an intracerebral haemorrhage. � She died in hospital on 31 October 2023 as a result of the intracerebral haemorrhage.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � The family of Mrs Woollen. � I have also sent it to Sheffield City Council who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Care Home Health related deaths This report is being sent to: Deerlands Residential Home
15/12/2023	2023-0527	John Thomas	North Wales East and Central	Denbighshire County Council (�the Local Authority�)	On the 6th of December 2023 an investigation was commenced into the death of John Michael Thomas (DOB 4/5/94) who died on the 2nd of December 2023 following a road traffic collision on the A539 outside Llangollen. An inquest has been opened in relation to Mr Thomas� death and has been adjourned to allow a Roads Policing Investigation to provide evidence concerning this death.	The death occurred when the deceased lost control of the motorcycle he was riding and collided with an oncoming vehicle, sustaining fatal injuries as a result.	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 This report is being sent to: Denbigshire County Council
28/12/2023	2024-0010	Adrian Gallagher	Cheshire	Department for Health and Social Care National Crime Agency Department for Science, Innovation & Technology	On 17 November 2017 I commenced an investigation into the death of Adrian Brendan GALLAGHER aged 24. The investigation concluded at the end of the inquest on 19 December 2023. The conclusion of the inquest was that: � This was a death due to suicide.	Adrian Gallagher had a history of mental health struggles dating back to 2013, with no definitive diagnosis. On 12 June 2017 he was admitted to Hollins Park Hospital as an informal patient, but was discharged at his request on 16 June 2017.� The same day, he was taken to hospital having been found intoxicated at a bridge, with suicidal ideation. He was formally sectioned under the Mental Health Act the following day and re-admitted to Hollins Park. During the admission, Adrian�s condition appeared to stabilise with changes to his medication, and he was allowed long periods of unescorted leave. By August 2017 he was awaiting a bed at Lea Court, a rehabilitation unit, and was spending the majority of the day away from the hospital. His presentation during this period did not give the hospital team or his parents cause for concern in relation to self harm/ suicidal ideation. On 9 November 2017 Adrian returned to hospital following a period of leave at his father�s house. No concerns or changes to his presentation were noted. Sadly, he was found deceased in bed the following morning, with his death confirmed at 08.50 on 10 November 2017. His death was due to an intentional [REDACTED] overdose. � Police interrogation of Adrian�s phone after his death identified that on 12 September 2017 he made a purchase from [REDACTED]. It is not clear from the phone records what that purchase was, but it was the evidence at the inquest that the most likely purchase was the [REDACTED].[REDACTED]. It was the evidence of the attending police officer that, although not easy to do, you can also buy [REDACTED] through the site. [REDACTED].	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons � Mr Gallagher�s family Mersey Care NHS Foundation Trust � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) This report is being sent to: Department of Health and Social Care
30/07/2024	2024-0544	Bethany Langton	Nottingham City and Nottinghamshire	Department for Health and Social Care, National Suicide Prevention Strategy Advisory Group Department for Science, Innovation and Technology	On 11 May 2023, I opened an inquest touching the death of Bethany Paige Langton, aged 22 years.� The inquest concluded on 8 July 2024.� The conclusion of the inquest was that Beth had died by suicide.	On 18 February 2023, Bethany Paige Langton was discovered deceased inside her bedroom at [REDACTED], having died following the ingestion of [REDACTED] which she had sourced online in January 2023. Beth had used the internet to research how to die using [REDACTED] and followed the advice she had found online. Beth deliberately ingested the substance with the intention of bringing about her death. Beth was vulnerable having been diagnosed with complex mental health diagnoses.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons�� Beth�s Family [REDACTED] [REDACTED] Clinical Psychologist [REDACTED] GP [REDACTED] Nottinghamshire Healthcare NHS Foundation Trust Nottinghamshire County Council [REDACTED] CQC � This report is shared with the recipients in unredacted form, but any published version of this report shall be redacted to avoid the risk of becoming a source of information available on the internet about this substance � 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)	Department of Health and Social Care \| Department for Science Innovation and Technology
21/01/2025	2025-0036	Paul Williams	Manchester South	Department for Levelling Up, Housing and Communities (Local Government.)	On 2nd August 2024 I commenced an investigation into the death of Paul Williams. The investigation concluded at the end of the inquest on 9th December 2024. The�conclusion of the inquest was suicide. The medical cause of death was 1a) hanging.	On 9th July 2024, Paul Williams was found suspended from a ligature outside Screwfix at Unit 5 Haigh Park. Police found no suspicious circumstances.	I have sent a copy of my report to the Chief Coroner and to the following Interested� Persons the partner of Mr Williams on behalf of the family who may find it useful or of interest.� I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it� useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief� Coroner.	Suicide (from 2015)	Ministry of Housing, Communities & Local Government
15/02/2023	2023-0123	Natalie Young	Somerset	Department for Transport Great Minster House 33 Horseferry Road London SW1P 4DR � FAO: The Rt Hon Mark Harper MP	On the 16th April 2022 the then-Senior Coroner, Mr Tony Williams, commenced an investigation into the death of Natalie Ann Young, aged 92 (�Natalie�). � The investigation concluded at the end of the inquest, heard before me, on the 8th��February 2023. The conclusion of the inquest was Accidental death, including medical cause of death being la) Lolwer respiratory tract infection lb) immobility le) fall with a humeral fracture 11) Frailty � With a finding in box 3 that: Natalie Ann Young, aged 92, died at Musgrove Park Hospital on the 13th April 2022 from a lower respiratory tract infection which she was more prone to develop following a period of immobility after an incident on the 9th March 2022 where she was knocked over by a mobility scooter. She sustained a humeral fracture during this incident but, on the balance of probabilities, the trauma and insult was too much for her physiological reserve, despite being an very active and spritely 92 year old lady.	Natalie was an independent (and somewhat spritely) 92 year old lady who had full mobility. On the 9th March 2022, Natalie was shopping on her own in a supermarket and was queued at the tills to pay for her groceries. Whilst she was waiting to be served, another shopper on a mobility scooter has joined the queue and was waiting, stationary. � Without warning the mobility scooter accelerated forward, ploughing into Natalie with some force and knocking her over. The forward propulsion of the mobility scooter was a conscious act of the driver/rider rather than an unforeseen mechanical or electrical fault. � On becoming aware of the injury caused to Natalie, the mobility scooter driver flees the scene and has not been identified or heard from since. � An ambulance was called but declined to attend and so staff from the supermarket transport Natalie to Musgrove Park Hospital where, on admission, it is discovered that she has sustained a fractured hummerus. Whilst she was medically fit for discharge throughout the duration of her stay in hospital, she required physiotherapy and occupational therapy assessments as part of her discharge planning. Natalie was ultimately discharged from hospital on the 9th April 2022 with a package of care in place. � Natalie suffered from immobility as a result of the injury, as well as severe pain. � She was re-admitted back into hospital on the 13th April 2022 when she was diagnosed with severe sepsis and an acute kidney injury due to a lower respiratory tract infection which had arisen solely as a consequence of the injuries she had sustained, and the resultant immobility, following a fall. Natalie died on the same day.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (i)�[REDACTED] (Natalie�s son); and [REDACTED] � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: Department for Transport
09/01/2025	2025-0011	Maria Simpson	Gloucestershire	Department of Health & Social Care	On 23 April 2024 I commenced an investigation into the death of Maria Simpson. The investigation concluded at the end of the inquest on 8 January 2025. The conclusion of the inquest was by way of narrative conclusion recording the facts set out in box 4. below.	On 4 August 2022 Maria attended her GP advising that she was pregnant and that she had been prescribed heparin during her previous pregnancy. She asked whether this was necessary again. � Her GP made a referral for advice to a hospital. The GP did not mention in the referral that there had been historic instances of recurrent pulmonary embolisms, albeit this did not contribute to Maria�s death. � The referral was returned to the GP by an administration officer at the hospital without a clinician seeing the same. The evidence was that this probably made more than a minimal contribution to Maria�s death as a clinician would have advised immediate administration of heparin. � The referral was then dealt with by another hospital. The GP was advised by the hospital to refer Maria to the obstetrics service. Thromboprophylaxis was recommended once pregnancy was confirmed. Evidence given was that the clinician that responded to the GP�s referral was not aware of the risk of bleeding associated with heparin as known at that time. With that knowledge, that clinician would have recommended the immediate administration of heparin without waiting for clinical confirmation of pregnancy. � The GP endeavoured to contact the obstetric service via the community midwife team. The electronic request was not accessed, due to staff leave, until after Maria�s death on 24 August 2022. � The cause of death was recorded as massive recurrent pulmonary thromboembolism and deep vein thrombosis.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons. (Through legal representatives) The family of Maria Simpson, Gloucestershire Hospitals NHS Foundation Trust, University Hospitals Bristol & Weston Foundation Trust, [REDACTED]. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Community health care and emergency services related deaths	Department of Health and Social Care
10/12/2024	2024-0681	Karen Dack	Leicester City and South Leicestershire	Department of Health & Social Care 39 Victoria Street London SW1H 0EU By Email only to :- [REDACTED]	On 29 May 2024 I commenced an investigation into the death of Karen Pamela DACK aged 43. investigation concluded at the end of the inquest on . The conclusion of the inquest was that: The cause of death was established as: I a Sepsis I b Spontaneous Bowel Perforation I c Sigmoid Diverticular Stricture II	Ms Dack had worsening symptoms of stricture and obstruction of the bowel. She had a colonoscopy on the 21 December 2023 which showed a stricture of the bowel.� In April 2024, following admission via the emergency department, planned urgent surgery did not happen because there were no intensive care beds and her condition had appeared to have resolved.� She was fast tracked to have an elective bowel resection on the 17 May 2024. On the 02 May 2024, following another emergency admission she again had urgent surgery planned but it did not go ahead due to her surgery being superseded by other more urgent cases.� Her treating consultant told this inquest that it was his plan to take Karen back to theatre the next day but this was not clearly communicated and Karen was discharged with the elective surgery still to take place as previously planned on the 17 May 2024, which was the plan written in the electronic records.� There was no assessment by any senior surgeon as to Karen�s fitness to be discharged and there was confusion about the management plan by the nurses on the ward. Karen re-presented to the emergency department four days later with worsening abdominal pain, vomiting and diarrhoea.� She had not suffered a perforated bowel at the time of admission, but the plan was that she should be taken to theatre for a laparoscopic bowel resection the following day.� Due to the volume of operations at this time this did not take place on the 07 May and was planned for the next day.� It is clear from the evidence that Karen�s condition deteriorated suddenly on the morning of the 08 May 2024, most likely due to perforation of her bowel. Once this was recognised surgery was completed urgently but Karen did not recover and became� septic� and� sadly� died� despite� the� surgeons� attempts� to� save� her� with� several� further operations.�� The evidence heard is that had Karen had any of the planned operations before her bowel perforated on the 08 May she would have survived.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 1)��The deceased�s family 2)� University Hospitals of Leicester I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths	Department of Health and Social Care
20/12/2023	2023-0537	Gregor Lynn	Cambridgeshire and Peterborough	Department of Health and Social Care Cambridgeshire & Peterborough Integrated Care System NHS England	On 29 July 2022, I commenced an investigation into the death of Gregor Patrick Edward Lynn aged 24 years. The investigation concluded at the end of the inquest on 30 August 2023.� The conclusion of the inquest was that: � Gregor died of natural causes due to a disseminated metastatic melanomaHe had developed a lesion on the back of his neck in March 2019 which was excised privately but the excised material was not sent for histological analysis, likely due to the additional cost associated with having to have the samples analysed privatelyBy the time the lesion recurred in May 2020 and was examined under the urgent care dermatology pathway, it was found to be a melanoma which had metastasised and was beyond effective treatment.	In March 2019, the consequence of Gregor not meeting the referral criteria for NHS treatment upon initial presentation with a nuisance lesion to the back of his neck was that he had to self-refer for private treatment at a reported cost of c.�140. He was advised that the additional cost of histological analysis of the excised samples would be c.�65 and so decided not to have the samples sent for analysis. When the lesion continued to trouble him in May 2020, he returned to his GP who referred him to dermatology, where a further excision was performed and analysed and was found to be melanoma. An ultrasound scan showed that the melanoma had metastisised to his lymph nodes, chest wall and lungs. Despite immunotherapy and targeted oral therapy, the melanoma continued to metastasise and in June 2022, scans showed that it had spread to Gregor�s brain such that his condition was terminal. He was placed onto a palliative care pathway and following an admission to Addenbrooke�s hospital on 6 July 2022, he died on 8 July 2022.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Family of Gregor Lynn [REDACTED] GP � as well as the other recipients identified at the top of the report. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form.� He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care \| Cambridgeshire Peterborough Integrated Care System \| NHS England
14/02/2024	2024-0084	Alfie Nicholls	Manchester South	Department of Health and Social Care Department of Education The National Institute for Health and Care Excellence (NICE) Greater Manchester Integrated Care	On 20th December 2021, I commenced an investigation into the death of Alfie Anthony Kevin Nicholls. The investigation concluded on the 12th January 2024 and the conclusion was one of Narrative: Died suddenly where his death was contributed to by malnutrition which was caused by a severely restricted diet and where the level of malnutrition and the consequential risk it posed was not recognised by professionals until after his death. � The medical cause of death was 1a) Sudden death in child with features of malnutrition on a background of developmental delay and an autistic spectrum disorder	Alfie Anthony Kevin Nicholls was a child with autism who was in full time education at a special school and was under the care of the child development unit. He was also known to children�s services, and there was an allocated social worker to support him and his family. As a consequence of his autism and sensory issues, Alfie had a difficult relationship with food and a restricted diet from a young age. Following him starting school, his diet became increasingly more restricted. Health, Education and Social Services professionals involved in his care did not communicate effectively between themselves or with his family about his diet and so did not have a clear understanding of how severely restricted his diet had become and how extremely limited it was in nutritional value. The risk that his nutritionally poor diet could present to his physical health was not understood or recognised by professionals involved in his care. � On 17th December 2021, he collapsed at his home address and was taken to Stepping Hill Hospital. Attempts to resuscitate him were unsuccessful and he died at Stepping Hill Hospital on 17th December 2021. A post-mortem examination found evidence of significant malnutrition caused, on the balance of probabilities, by his severely restricted diet, that on the balance of probabilities, contributed to his collapse and death on 17th December 2021	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) [REDACTED] ; 2) [REDACTED] 3) Stockport NHS Foundation Trust; 4) Lisburne School; 5) Stockport Metropolitan Borough Council, who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Child Death (from 2015) This report is being sent to: Department of Health and Social Care \| Department for Education \| The National Institute for Health and Care Excellence \| Greater Manchester Integrated Care
24/04/2023	2023-0133	Samuel Howes	South London	Department of Health and Social Care NHS England	INVESTIGATION AND INQUEST: Samuel Thomas Howes � On 17th September 2020, the Senior Coroner commenced an investigation into the death of Samuel Thomas Howes. The investigation concluded at the end of the inquest on 30th March 2023. � Medical Cause of Death � 1a Multiple Traumatic Injuries � How, when and where and, for investigations where section 5(2) of the Coroners and Justice Act 2009 applies, in what circumstances the deceased came by his or her death. � Shortly after 9am on 2 September 2020, Samuel Thomas Howes suffered fatal injuries when he jumped in front of a train [REDACTED] He did so in the following circumstances: � a) Samuel suffered from ongoing mental health issues including anxiety and depression. b) Samuel�s mental health led to his use of drugs and dependency which exacerbated his poor mental health. c) Samuel was a looked-after child, living in a placement residence. d) That he was free to, and did, leave that residence e)�That early on 2 September 2020, he was recorded by police as being a �missing person� f)��That police did not succeed in finding him before he jumped in front of the train � Below are also matters admitted by interested persons: � a)�Following Samuel�s arrest on 30 August 2023, neither of the safeguarding forms (specifically, a CYP and a DASH form) was completed by officers of the British Transport Police (BTP) b) The Metropolitan Police Service (MPS) did not request Samuel be assessed by healthcare professionals (in particular a Custody Nurse Practitioner or a member of the Liaison and Diversion Team) while in custody on 30-31 August 2020. c) The MPS did not progress the investigation to locate Samuel after 3:15pm on 2 September 2020 and before actions were set at 08:04am on 2 September 2020.	A jury found: Suicide� Samuel�s mental health and his use of drugs and/or alcohol probably contributed to his death. � We believe that the following matters also possibly made more than minimal, trivial or negligible contributions to his death � a)�The inadequate response of mental health and social care services in relation to Samuel�s dependency on alcohol and the possibility of a rehabilitative placement. � There were inadequate provisions for Samuel�s complex needs. In particular, it was noted that no alternative treatments were proactively pursued. The agencies identified Covid as an obstacle to justify their inadequate responses. � b)�The failure to inadequately share risk information by Social Services and/or Mental Health Services with each other, and with the police. � A number of factors were noted in this regard: � ��Missing risk assessments were not completed consistently � ��The Grab Pack was not completed � ��iii) Samuel�s vulnerabilities and suicide notes were not adequately communicated to the police by Social Services c) The sharing of risk information by the MPS and/or BTP with partner agencies. � A number of factors were noted in this regard: ��There was a failure to share risk information by the MPS with BTP, as well as with partner agencies. ��In particular, there was a failure to complete and update the CYP Fonns, or Merlin, as a result of each agency using their own platfonn. ��In addition, the BTP did not access the PNC to identify Samuel�s Warning Markers � d) Steps taken by the MPS to seek an assessment of Samuel�s mental health by a Liaison and Diversion Practitioner whilst he was in custody on 30 and 31 August 2020 � The following was noted in this regard: ��Actions noted on THRIVE regarding the provision of a mental health assessment for Samuel were not followed up on multiple occasions. � e) The inadequate approach of staff and the safeguarding processes within Croydon Custody Suite � A number of factors were noted in this regard: � ��Samuel�s actions were regarded as �attention-seeking�. ��The DASH and CYP Fonns were not completed. ��The limited collaboration between the MPS and BTP led to a lack of recognition of Samuel�s mental health needs, resulting in inadequate care. � f) Failures by multiple agencies and the inadequate response to the �missing persons� investigation conducted by the MPS � A number of factors were noted in this regard: ��Failure to share infonnation by different agencies ��Failure by multiple agencies to contact Samuel�s family when he went missing. � g) Samuel�s interactions with his girlfriends The following was noted in this regard: ��Samuel�s relationships were described as �chaotic� and this impacted on his mental health and his behaviour �� In particular, the texts from his girlfriends telling him to �kill himself as well as the threats by another girlfriend to end her life, had a significant impact on Samuel�s behaviour.	I have sent a copy of my report to the Chief Coroner and to the following interested Persons: � ��The family of Samuel Thomas Howes ��London Borough of Croydon ��South London and Maudsley NHS Foundation Trust ��The Childrens Commissioner (the deceased being a minor at the date of death). I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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) \| Railway related deaths This report is being sent to: Department of Health and Social Care \| NHS England
04/07/2024	2024-0359	Michael Walton	Newcastle and North Tyneside	Department of Health and Social Care NHS England	On 20th July 2023 I commenced an investigation into the death of Michael Trevor Walton, 66. � The investigation concluded at the end of the inquest on 3rd July 2024. � The medical cause of death was 1a) Ischaemic hypoxic brain injury; 1b) Aortic arch injury during coronary artery bypass procedure. � The conclusion of the inquest was that Mr Walton died due to a very rare complication of a necessary surgical procedure.	Mr Walton suffered from coronary artery disease for which he elected to undergo a coronary artery bypass procedure. He was a good candidate for the surgery and at low risk of complications. The procedure was undertaken on 13th June 2023. The Consultant Surgeon�s preferred choice of cannula was not available due to supply issues and a cannula with a slighter shorter tip was therefore used by the operating surgeon. During the course of the procedure, the aortic cannula became dislodged causing a loss of perfusion and a prolonged period of interrupted blood flow to the deceased�s brain which caused an ischaemic hypoxic brain injury from which he died on 13th July 2023 at the Eden Valley Hospice, Durdar Road, Carlisle.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, the family of Michael Trevor Walton and Newcastle upon Tyne 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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Department of Health and Social Care \| NHS England
27/11/2023	2023-0483	Boycie Chatterton	Inner West London	Department of Health and Social Care (DHSC) NHS England (NHSE)	An investigation was commenced into the death of Boycie [Alexander/Chatterton], aged 6 weeks. The investigation concluded on 1 September 2023.� The conclusion in the inquest was: � Complication following surgical procedure � The medical cause of death was � 1a Hypoxic-ischaemic brain injury 1b. Multiple respiratory arrests 1c. Complications following oesophageal atresia and tracheo-oesophageal fistula repair procedures. 2. VATER association.	B was born at 36 weeks and 6 days gestation. At birth B was diagnosed with congenital abnormalities including Oesophageal Atresia (OA) and Tracheo-Oesophageal Fistula (TOF), a condition denoted by a blind-ending upper oesophagus with the lower oesophagus connected to the trachea, which affects about 200 babies a year in England. B had an initial surgical procedure to disconnect the TOF and join the oesophagus, but the gap between the two parts of the oesophagus was too great at that time to join. This is known as long gap Oesophageal Atresia (OA), a condition which affects about 20 babies a year in England. Management of long gap OA is very significantly more challenging than non-long gap OA. There are different options for treatment of long gap OA. In this case the surgical team applied tension sutures to draw the oesophageal ends closer for later joining. B had a second planned surgical procedure to check whether the oesophagus was capable of being joined and it was not. At the third planned surgical procedure, an oesophageal anastomosis was performed. Following the third surgical procedure, B developed respiratory complications as a result of which he died.	I have sent a copy of my report to the Chief Coroner and to the following: 1. [REDACTED] 2. [REDACTED] 3. Chelsea and Westminster Hospital NHS Foundation Trust 4. TOFS 5. [REDACTED], Birmingham Children�s Hospital 6. [REDACTED], Great Ormond Street Hospital � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.	Child Death (from 2015) This report is being sent to: NHS England \| Department of Health and Social Care
13/10/2023	2023-0403	Peter Carr	North London	Department of Health and Social Care 39 Victoria Street London, SW1H 0EU	On 5th October 2021 I commenced an investigation into the death of Peter Carr. The investigation concluded at� the� end� of� the� inquest� held on the 9th,10th and 11th of October 2023. � The conclusion of the inquest was a short narrative conclusion; � Peter Carr died from a recognised complication of necessarily prescribed medication.	On the 25th of August Mr. Carr developed a rash. By the 31st most of his skin was red so he presented to the North Middlesex Hospital A&E where he was admitted by the medical team. He also had neutropenia and lymphadenopathy.The admitting doctor prescribed tazocin, a rare side effect of which is Stephens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN.) The North Middlesex outsources dermatology. Mr. Carr first saw a dermatologist 3 days after admission at which point there was no sign of SJS / TEN. Nevertheless skin biopsy � something every consultant dermatologist can do � was deemed necessary but the attendant dermatologist, who could have done this, did not becaue the company�s process is to ask a plastic surgeon to biopsy. It took until the 8th for the biopsy to be taken. There was no dermatological oversight of Mr Carr�s skin in the intervening time. The biopsy found evidence of drug reaction consistent with SJS. An optimum dermatology service was described by our expert as patients being seen by a consultant dermatologist and biopsied if required within 24 hours of presentation, and then watched like a hawk on a daily basis. Had this happened the emergence of SJS may have been recognised and prompted withdrawal of the culprit medication. That this level of dermatological support was not available denied Mr. Carr �a role of the dice� � a chance of survival.	I have sent a copy of my report to the following. � ?��The Family. ?��Omnes Healthcare. ?��The North Middlesex University Hospital. ?��University College London Hospital. ? ��[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: Department of Health and Social Care
14/11/2023	2023-0449	Maxwell Frame	West Yorkshire (Western)	Department of Health and Social Care 39 Victoria Street, London SW1H 0EU National Institute for Health and Care Excellence Redman Place, London E20 � Royal College of Anaesthetists Churchill House, 35 Red Lion Square, London WC1R 4SG � Academy of Medical Royal Colleges 10 Dallington Street, London, EC1V 0BD � National Infusion and Vascular Access Society � Association of Anaesthetists 21 Portland Place, London, W1B 1PY	On 14 July 2021 the death of Maxwell Frame was reported to the Coroner for West Yorkshire (West). An inquest was opened on 28 July 2021. An inquest was heard between 9 and 11 October 2023. The medical cause of death (accepted from a report in lieu) was 1a) Acute Ischaemic Strokes (Multifocal); 1b) Inadvertent Insertion of a Central Venous Cather in the Common Carotid Artery; 2 Perforated Acute Appendicitis Leading to Septic Shock. � The conclusion was one of misadventure contributed to by neglect.	Mr Frame had presented to the A&E department at Huddersfield Royal Infirmary (Part of Calderdale and Huddersfield NHS Foundation Trust- the Trust) in the early hours of 24 June 2021. Investigations identified a pelvic abscess and bowel obstruction as the source of sepsis which was not amenable to radiological drainage. He underwent an emergency laparotomy the same day with findings of a pelvic abscess from a perforated gangrenous appendix and non-viable adjacent colonic tissue and small bowel obstruction. This required drainage of the abscess, removal of the gangrenous tissue and bowel and formulation of a stoma. As part of the pre-surgical preparations for post operative care the placement of a central venous catheter (CVC) was undertaken using the right subclavian vein. A landmark approach was used. There was no use of ultrasound to assist placement of the CVC despite this being available. As part of the checks to ensure correct placement of the CVC a check chest x-ray was undertaken. Other checks in the form of an arterial blood gas and transducing the intra-vessel pressure wave via the CVC were not undertaken even though the necessary equipment to do so was available. The check chest x-ray was incorrectly interpreted as showing correct placement into the vein whereas, in fact, the CVC had been incorrectly placed into the artery. The check chest x-ray was not reviewed by the consultant who had undertaken the procedure until a later point after discovery that the CVC had been incorrectly placed. Whilst the evidence identified incorrect placement of a CVC was a recognised complication, it was accepted that the various steps detailed above that would have reduced this happening were not undertaken. The incorrect placement of the CVC was identified on 27 June 2021. Following this Mr Frame was transferred to the Bradford Royal Infirmary. On 1 July 2021 he underwent a procedure to remove the misplaced CVC. In the course of this procedure some clot adherent to the CVC dislodged and embolised into his brain circulation causing stroke damage, the extent of which was such that, following discussions with Mr Frame�s family, he was commenced on palliative care. He was extubated and died on 13 July 2021.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Mr Frame Bradford Teaching Hospitals NHS Foundation Trust Weightmans LLP acting for the Trust � [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.	Hospital Death (Clinical Procedures and medical management) related deaths	Department of Health and Social Care \| National Institute for Health and Care Excellence \| Royal College of Anaesthetists \| National Infusion and Vascular Access Society \| Association of Anaesthetists
10/10/2023	2023-0380	Alex Dews	South Yorkshire (Western)	Department of Health and Social CareDepartment of Education	On 21 July 2022 I commenced an investigation into the death of Alex Dews born on 7 November 2008. The investigation concluded at the end of the inquest on 7 September 2023. The conclusion of the inquest was: � On 14 July 2022 Alex Dews went to a bridge in Dearne Valley Country Park, Barnsley. He fell from the bridge to the shallow river below. It is not clear the mechanism of that fall as this was unwitnessed. It is also not clear whether Alex intended to end his life in the fall from the bridge. Alex was found by someone passing and the ambulance service attended and transported him to Sheffield Children�s Hospital where he died on 18 July 2022. The medical cause of death was: 1a: Hypoxic Ischaemic Brain Injury 1b: Traumatic Brain Injury and Drowning	Alex Dews was born on 7 November 2008. � Alex was born female however in his teenage years he identified as male and asked for his mum to notify his school of his change of name. Alex was loved and well supported by his family throughout his life and his family were a big source of security and support and he could readily talk to them about what he was experiencing. � Alex�s school acknowledged Alex�s decision about his identity and immediately ensured this was communicated with the relevant people within the school and placed him on the vulnerable register in line with established practice. � Due to Alex�s protected characteristic this meant that he would be discussed on a weekly basis. Although there are no minutes of this meeting it is clear on the basis of the evidence that I have heard that he was discussed on a weekly basis although there were not always actions which were needed. � There was an incident on 4 November 2021 [REDACTED]. There is evidence that this was on school premises and he was seeking advice from his grandmother about what to do. His grandmother has indicated in evidence that she was contacted by the school who outlined the injury. This is not documented by the school however I am satisfied on the balance of probabilities that this incident happened and the communication is as Alex�s grandmother has described. � There was then a further incident which was disclosed to Ad astra about self harm and that resulted in Alex being placed on the waiting list for iSpace (the schools counselling service) at his mother�s request. This was documented on the vulnerable register on 22 November 2021. � On 15 March 2022 Alex wrote a letter in school which he gave to one of his teachers indicating he wished to end his life. This resulted in a risk assessment by the safeguarding lead who subsequently pushed Alex up the iSpace waiting list and advised his mother to take him to A&E if she was concerned. � On 23 March 2022 there was a further disclosure that Alex wanted to kill himself to staff at the school. � On 25 March 2022 Alex commenced the counselling services from iSpace. � During the second session of counselling Alex disclosed that he had taken an overdose [REDACTED]. This was conveyed from the Counsellor to the school safeguarding team and family were made aware of the disclosure. � In May 2022 Alex had received his full sessions of counselling and was discharged from those counselling functions. The discharge email made reference to Alex potentially benefitting from these services in future but there was no time frame on this. � It would appear that from the records and the evidence which I have heard there was an escalation in Alex�s behaviour towards staff and involvement at school. This was out of character for Alex and his family would invite me to consider that this was evidence of Alex�s deteriorating mental health. � That said, Alex�s last report at school indicated that he was putting in significant amounts of evidence at school and doing well. After his discharge from counselling services in May 2022 there is no evidence of episodes of self harm or suicidal thought in school documentation however he was still discussed each week on the vulnerability register meeting. � Staff were concerned that Alex would struggle in the following year of school and therefore determined that it was appropriate at that point to make a referral into CAMHS services for Alex. This had previously been discounted on the basis that the waiting list was so long and that if Alex was in receipt of iSpace support he would not be eligible for CAMHS services. � The CAMHS referral was made on the 27 June 2022. I have not heard any evidence longer term. � I am satisfied on the balance of probabilities that there was no real and immediate concerns for Alex�s mental health which the school had and could reasonably have done anything about from May to the point at which Alex died. � That said, there are concerns about the way in which the school have documented matters and the way in which the school assess and check the assessments of pupils when there are concerns. � I am also concerned that the information shared with iSpace and others is hugely subjective and not standardised in any way shape or form. I am concerned that the school is not provided information from iSpace in the form of a final report not about what the child has disclosed but in respect of any advice and guidance which is given or any other follow up actions that are required (such as future sessions being planned). � I am satisfied that the referral to CAMHS was a pre-emptive measure in anticipation of Alex�s following year at school. Had staff felt that Alex was at immediate risk when they made the referral on 27 June 2022 I am satisfied that they were less likely to make a referral to CAMHS and instead would have advised A&E or an escalation to iSpace. This is on the basis of the evidence which I have heard regarding the difficulties staff have had over making referrals to CAMHS.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Alex�s family and Outwood Academy Trust. � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any other person who I believe may find it useful or of interest. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.	Other related deaths This report is being sent to: Department of Health and Social Care \| Department for Education
10/11/2022	2022-0417	Michael Smith	County Durham and Darlington	Director General Prisons HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ	On 23 July 2020 I commenced an investigation into the death of Michael Raymond SMITH aged 31. The investigation concluded at the end of the inquest on 09 November 2022. The conclusion of the inquest was: � Misadventure. � And the jury added this narrative to that conclusion: � The fact that the scanner revealed he was plugged with drugs; The manner in which control and restraints, and the strip search were conducted, and a failure to de-escalate; The absence of any mental health assessment during Michael�s arrival in reception and being discovered suspended in his cell; The absence of a medical assessment during Michael�s arrival in reception and being discovered in reception; and Michael�s use of drugs,� during his time on SACU � The above were all contributions that were more than minimal, negligible or trivial and probably contributed to Michael�s death. Each presented and opportunity to do something, or not do something, that would have probably prevented Michael�s death.	Michael entered HMP Durham on 10 July 2020. Body scan revealed he was plugged with packages. He was transferred to SACU. There was control and restraint incidents on the way an on arrival, where he was strip searched. He was placed and remained on 3 man unlock for his entire time there. At 17.45 on 11 July he was discovered self-suspended. Paramedics achieved the return of spontaneous circulation, but he died at University Hospital North Durham on 13 July 2020. � The medical cause of death was: 1) a) Hypoxic brain injury b)� Cardiorespiratory arrest c)� Hanging � Toxicology on hospital admission bloods showed toxic levels	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.	Suicide (from 2015) \| State Custody related deaths	HM Prison and Probation Service
19/01/2023	2023-0019	Joseph Price	County Durham and Darlington	Director of Health and Justice, Armed Forces and Sexual Assault Referral Centres for NHS England, Chief CORONER CC OFFICE	On 24 September 2020 I commenced an investigation into the death of Joseph Andrew PRICE aged 28. The investigation concluded at the end of the inquest on 18 January 2023. The conclusion of the inquest was that the death was from Natural Causes.	On 20 September 2020 Joseph Andrew Price (Andrew), born 05 December 1991, was found dead in his cell on A Wing at HMP Durham. The opinion initially provided by the pathologist was that the cause of death was unascertained. However, having heard evidence at the Inquest of a paternal family history of pre-mature cardiac related deaths, she changed this to Sudden Cardiac Death.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] I have also sent it to [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.	Other related deaths \| State Custody related deaths	Director of Health and Justice, Armed Forces and Sexual Assault Referral Centres for NHS England
22/12/2022	2022-0413	Glenys Phipps	Gwent	Director of Nurse and Health Professional Education, Health Education and Improvement Wales (HEIW))	INVESTIGATION AND INQUEST � On 5/10/2020 an investigation was opened into the death of Glenys Lillian Phipps The investigation concluded at the end of the inquest on: 8/12/2022 The conclusion of the inquest was recorded as: � Death by Accident. � � The medical cause of death was: � 1a Subdural haematoma 1b Fall � 2. Advanced Vascular Dementia. Hip Fracture, CVA, Osteoarthritis, hypertension, Pancreatitis, gallstones, poor mobility	Glenys Lillian Phipps was admitted to hospital on 3/9/2020 for investigations of abdominal pain. Glenys suffered with dementia and was confused in hospital. There was an inadequate assessment of her risk of falling and no personalised care plan was developed to reduce the risk. Glenys fell twice in hospital. The second fall on 17/9/20	COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Person (s) � The family of Glenys Phipps Health Inspectorate Wales. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief coroner.	Hospital Death (Clinical Procedures and medical management) related deaths \| Wales prevention of future deaths reports (2019 onwards)	Health Education and Improvement Wales
07/09/2023	2023-0381	Lamont Roper	North London	Directorate of Legal Services, Metropolitan Police Service, Holborn Police Station, 10 Lambs Conduit Street, London, WC1N 3NR	On 8th October 2020 I commenced an investigation into the death of Lamont Ashley Roper. The investigation concluded at the end of the inquest held on the 22nd November 2021. The medical cause of death was 1(a) consistent with drowning. The conclusion of the Jury at the inquest was:- � 1.�� Non compliance with stop and search request. 2.��Inadequate recourses for water rescue along the canal and Lock 19. 3.� Lack of sufficient police resources. 4.� Lack of specialised on call rescue team (ie Divers).	Mr Roper was found dead at the bottom of Lock 17 after entering the water the previous night. Mr Roper entered the water after an initial cycling pursuit along the tow path between Marksfield Park and Lock 17. Mr Roper was issued with a stop and search request which was ignored. Mr Roper then had a struggle with a police officer after falling off his bicycle adjacent to Lock 17. The Struggle continued at the railings closest to the canal, and after a brief time the police officer shouted �GO GO� and released Mr Roper who shortly afterwards fell into the canal.	I have sent a copy of my report to the following. � ?�� The Family�s Solicitors, ?�� The Met Police . I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Other related deaths This report is being sent to: Metropolitan Police Service
19/01/2023	2023-0018	Derek Larkin	Dorset	Dorset Council Dorset Clinical Commissioning Group	On the 31st August 2021, an investigation was commenced into the death of Derek Larkin, born on the 10th January 1964. The investigation concluded at the end of the Inquest on the 12th January 2023. The Medical Cause of Death was: 1a Fatal intoxication with morphine. � 2 Chronic Ischaemic heart disease with Stenosing Atherosclerosis of the Coronary arteries � The conclusion of the Inquest recorded Accidental death.	Derek Larkin had a known history of misusing his prescription medications. He had been living at home with a care package of support that included live in carers, up until his admission to hospital he had been dealt with by his local GP practice. He was admitted to Royal Bournemouth Hospital, on the 21st January 2021, suffering from Covid and pneumonia, he was successfully treated. On the 8th March 2021 he was discharged from hospital, he was not able to return home and went to reside in a care home. Whilst resident there he was dealt with by a different GP practice. He was prescribed medication. Dorset Council Adult Social Care were responsible for him and had drawn up a Care Plan. Derek Larkin wished to return to his home address and made this known to Adult Social Care in a telephone conversation on the 19th April 2021. Dorset Council liaised with the previous care providers the occupational health team, through a brokerage system they located a different care provider and made arrangements for Derek Larkin to return home on the 20th May 2021. Evidence from healthcare professionals at the inquest confirmed that Derek Larkin had capacity. On the 2nd June 2021 Derek Larkin was found deceased at home by a carer. A post mortem examination demonstrated that he had overdosed on his prescription morphine. From the evidence at the inquest, it is clear that Dorset Council Adult Social Care would have benefited from having knowledge of the medications that had been prescribed. It is clear that family members raised concerns with Adult Social Care about Derek Larkin�s access to medication. In addition Adult Social Care would have benefited from any further information from the current GP practice together with his regular GP practice to enable them to consider what might be included within his care plan to include where the medication might be stored and whether it was to be administered by care staff or whether Derek Larkin was self-administering his medication.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (1) [REDACTED] (2) [REDACTED] (3) [REDACTED] (4) Care Quality Commissioner I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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	Dorset Council and Dorset Clinical Commissioning Group
30/12/2024	2025-0031	Ian Harris	Shropshire, Telford & Wrekin	Driver and Vehicle Licensing Agency [REDACTED] Head of Strategy and Policy Longview Road� Morriston� Swansea SA6 7JL	On 28 August 2024 I commenced an investigation into the death of Ian Paul HARRIS. �� The investigation concluded at the end of the inquest on the 14 January 2025. The conclusion of the inquest was that the cause of death for the late Mr. Harris was due to a road traffic collision,� including the medical cause of death of multiple traumatic injuries.	On the 23 August 2024 the late Mr. Harris was driving a motor car on the A483 at Sweeney, Oswestry, Shropshire when it was in collision with an oncoming Heavy Goods Vehicle. �� Mr. Harris lost control of his vehicle and drifted across into the part of the oncoming vehicle due most likely to a medical condition.	I have sent a copy of my report to the Chief Coroner and to the family of the deceased and the other interested persons; DAC Beachcroft LLP, OCL Solicitors & JMW Solicitors LLP.� I have also sent it to West Merica Police Road Traffic Investigation Unit 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	Driver and Vehicle Licensing Agency
24/06/2024	2024-0337	Liam McCarlie	Northamptonshire	EAST MIDLANDS AMBULANCE SERVICE NHS TRUST NHS NORTHAMPTONSHIRE INTEGRATED CARE BOARD	On 5th April 2023 an investigation was commenced into the death of Liam Paul McCarlie. On 5th June 2024 I concluded the inquest into Mr McCarlie�s death. The conclusion of that inquest was a narrative conclusion: Liam Paul McCarlie died by suicide. From 15 February 2023 there was an insufficiently clear plan to support proactively Mr McCarlie�s mental health whilst he waited for formal assessment for suitability for the Structured Clinical Management programme. This possibly contributed to his death. On 1 April 2023 there was a significant delay in an ambulance attending upon Mr McCarlie following an emergency call. This delay was caused by an increased demand on the ambulance service. This delay contributed to Mr McCarlie�s death. The medical cause of death was: 1a Hanging	At around 23.23 on 1st April 2023 Liam Paul McCarlie was found by paramedics suspended by a ligature [REDACTED].� Mr McCarlie was not breathing, had no pulse and had a Glasgow Coma Scale score of 3/15. His heart rhythm was asystole. Earlier that evening he had exchanged text messages in which he had expressed an intention to take his own life. At around 17.52 his father and step-mother contacted the ambulance service. The call was assessed as requiring a 120 minute 90th centile response time. Paramedic led Double Crewed Ambulances had been allocated at 20.29 and 22.08 however both were stood down and reallocated to attend higher priority calls. At the time, the local ambulance service was experiencing a prolonged and significant increase in calls resulting in delays: a critical safety plan was in operation. A third paramedic led Double Crewed Ambulance was allocated at 22.50. That ambulance arrived [REDACTED] at 23.11, i.e. 5 hours and 19 minutes after the initial call and therefore significantly outside of the 90th centile for a call of this kind. Had the ambulance service arrived within the required response time, it would have done so at a time when Mr McCarlie was still alive. The last recorded call from Mr McCarlie was at 19.26 (a call lasting 2 minutes). The last recorded text message was sent by Mr McCarlie at 20.18. Death was confirmed at 00.33 on 2nd April 2023. In early February 2023 Mr McCarlie�s mental health deteriorated significantly. He was assessed by various mental health professionals, including a consultant psychiatrist. Mr McCarlie had previously attempted suicide in July 2021; following this he took anti- depressant medication until February or March 2023. On 15th February 2023 Mr McCarlie was identified as presenting with traits which were highly indicative of Emotionally Unstable Personality Disorder. He was referred to the Structured Clinical Management (�SCM�) programme. At the time of his death Mr McCarlie had not been formally assessed for suitability within the SCM programme.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Liam McCarlie. Northamptonshire Healthcare NHS Foundation Trust. The Greens Norton Medical Practice. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) \| Emergency services related deaths (2019 onwards) This report is being sent to: East Midlands Ambulance Service NHS Trust \| Northamptonshire Integrated Care Board
01/02/2023	2023-0038	Hugo Carlos	Berkshire	EMIS [Egton Medical Information Systems]	On 11th November 2021 I commenced an investigation into the death of Hugo Carlos (age 30 years). The investigation concluded at the end of an inquest on 12th January 2023. The conclusion of the inquests into the death was: Mr Carlos died from liver infarction and liver failure following an interventional radiology procedure to embolize bleeding from a fistula between the hepatic artery and bile duct. This was a recognised risk of a potentially life-saving and necessary medical procedure. The fistula developed following an interventional radiology procedure to insert a biliary drain into the bile duct. Bleeding following biliary drain insertion was a known risk of this medical procedure. The biliary drain was necessary to treat obstructive jaundice which was caused by a hepatocellular adenoma, which grew and obstructed the bile duct, causing Mr Carlos to experience symptoms of obstructive jaundice in late August 2021. The hepatocellular adenoma was first seen as an incidental finding on an ultra sound scan in March 2019. The hepatocellular adenoma was diagnosed as a focal nodular hyperplasia on MRI scan with contrast reported in June 2019. From a liver biopsy taken on 26th October 2021 and on Post Mortem the liver lesion was diagnosed not as a focal nodular hyperplasia, but as a hepatocellular adenoma.	The Deceased, Hugo Carlos, date of birth 22 May 1991, was 30 years old at the time of his death in November 2021. In March 2019 the Deceased had a check-up at a private hospital. An abdominal ultrasound scan showed a large vascular lesion in the liver. On 26 March 2019, the Deceased attended his general practice to discuss the scan result and an MRI scan was recommended. The MRI scan was undertaken on 29th May 2019. At a follow up GP appointment on 10th June 2019 it was advised that if the patient remained asymptomatic there should be an ultrasound scan in 1 year. The Deceased contacted the surgery and requested follow up scans in April 2020 and July 2021. Follow-up scans were arranged through the GP. In September 2021 an ultrasound scan showed that the liver lesion had increased in size and there was mild intrahepatic biliary dilatation. The Deceased was subsequently admitted to hospital on 12 October 2021 and sadly passed away on 8 November 2021. A post-mortem confirmed that the cause of death was due to acute liver failure and liver infarction following embolization of the hepatic artery to arrest severe haemorrhage as a consequence of a percutaneous biliary drain insertion for the management of obstructive jaundice secondary to a large hepatocellular adenoma.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: �� The family of Hugo Carlos �� Royal Berkshire NHS Foundation Trust �� Strawberry Hill Medical Centre I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths	Egton Medical Information Systems
15/07/2024	2024-0487	Phephisa�Mabuza	Central and South East Kent	ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST	On� 21� March� 2023� I� commenced� an� investigation� into� the� death� of� Phephisa� Siphelele MABUZA. The investigation concluded at the end of an inquest held on 29th April 2024. The conclusion of the inquest was:� Narrative- Phephisa Mabusa was found at the base of�[REDACTED]�Dover on the morning of 14th March 2023 having died from injuries consistent with a fall from height. He was last known to be alive at 14.18 on the afternoon of 13th March 2023 when he was sighted walking alone toward the area where he was later found. He had travelled from Southend on Sea� to� Dover� by� rail� and� had� withdrawn� cash� on� route.� He� had� not� taken� olanzapine prescribed for psychosis for a number of months and was hearing voices in the days before his death but had not voiced any intention to take his own life. The evidence does not disclose how he fell or his intention at the time, but his death likely occurred on 13th March 2023.� The medical cause of death was established following a post mortem to be from� 1a� Multiple Injuries	Phephisa Mabusa was diagnosed with psychotic disorder. He had been admitted to hospital as a result on a number of previous occasions, the last in July 2022 following which he was prescribed olanzapine in the community which he continued to take until the end of October 2022 when he moved out of the supported accommodation where he had been living and moved to Nottingham with his girlfriend.� Phephisa had been under the care of the Essex mental health team but was discharged from their service because of his move out of the county. His care co-ordinator advised him to register with a new general practitioner so his olanzapine prescription could continue and so that the mental health team could advise the new General practitioner of Phephisa�s contact with the Essex Mental Health Services. Whilst he registered with a general practitioner, he did not request a prescription.� He returned to Essex on 4th November 2022 and although the supported accommodation where he had been staying was available to him, he decided together with his mother that he should get a job and get his own place rather than live in supported accommodation. He moved in with his mother. Phephisa registered with a general practitioner in the following days but did not ask for his olanzapine prescription to be restarted.� His mother did not become aware that he had not been taking his medication until February 2023 when she noticed that symptoms her son started to have when in the early stages of psychosis appeared to have returned. She called his general practitioner on 3rd March 2023 but was not available when the GP called back. She made further attempts to contact his general practitioner on 7th March 2023, but on this occasion did not receive a response and therefore on 10th March 2023 rang the 111 service where she spoke to a mental health nurse who conducted a telephone triage speaking to both Phephisa and his mother. The mental health nurse�s conversation with Phephisa was very brief because Phephisa reported being tired.� The mental health nurse contacted the first response team to make a face to face appointment with Phephisa and also requested his general practitioner reconsider prescribing olanzapine again.� A prescription was sent electronically to the pharmacy, but the spine system disconnected and the prescription request would not go through. The prescription was not therefore available for collection on 13th March 2024, when Phephisa�s mother went to collect it. She did not see her son again and reported him missing when she returned from work the following day. Phephisa�s death had been reported to Kent Police 10 minutes before he was reported missing to Essex Police.	I have sent a copy of my report to the Chief Coroner and to the� following Interested Persons the legal representatives of the family I have also sent it to the senior coroner for Essex 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 \| �Community health care and emergency services related deaths	ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST
30/09/2024	2024-0518	Megan Williams	Central and South East Kent	East Kent Hospitals University NHS Foundation Trust (EKHT) National Institute for health and Care Excellence (NICE) NHS England	On 26th September 2022 I commenced an investigation into the death of Megan Williams. The investigation concluded at the end of the inquest on the 20th June 2023 although I delivered the conclusion on 24th October 2023. The conclusion of the inquest was that the deceased Megan Ceris Williams died as a result of (set out in a narrative conclusion) an undiagnosed small bowel obstruction, apparently caused by band adhesions from previous intraabdominal surgery. She had attended hospital twice, on both occasions via ambulance, on 2nd May (when she was discharged with suspected gastritis) and 4th May 2022 (when she self-discharged in the early hours of the following morning and returned home where she died). � The cause of death having been determined as: 1a Aspiration Pneumonia 1b Small bowel obstruction 1c� Strangulated internal hernia due to band adhesions from prior intraabdominal surgery 2	The deceased Megan Ceris Williams had had surgery for a previous burst appendix and that appears to have led to some band adhesions. More specifically Megan had had an appendicectomy in 2009. Adhesions identified on post mortem appeared to be in the same region as the appendix. � The deceased had developed some discomfort late in the evening on 1st May 2022 and by 3am the following morning (2nd May 2022) suffered violent vomiting. The 111 service was called, and the deceased was taken by ambulance to William Harvey Hospital. The deceased was discharged, on 2nd May 2022 and sent home with a diagnosis of gastritis. At around 4pm the deceased had telephoned her family asking them not to collect her from hospital because she had vomited (which was not captured in any medical records). � On 4th May 2022 the deceased was once again in severe pain and brought back to William Harvey Hospital by ambulance, after a long wait to be seen she left hospital at 1am, on 5th May 2022 and discharged herself (no signed documentary record of that self-discharge has been located). � At around 3am on 5th May the deceased vomited again, by 7.30am she became breathless and at around 8am,she sat up saying that she was going to vomit but abruptly lost consciousness � Emergency services were called, family members attempted resuscitation which was taken over by the ambulance service when they arrived. Resuscitation attempts continued for around two hours but were ultimately unsuccessful. � The deceased died at her home address [REDACTED] on 5th May 2022.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely the family and EKHT. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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	East Kent Hospitals University NHS Foundation Trust \| National Institute for Health and Care Excellence \| NHS England
17/05/2024	2024-0399	Antony Waring	Lancashire & Blackburn with Darwen	East Lancashire Hospitals Trust	On 29 June 2020 I commenced an investigation into the death of Antony Waring 70. The investigation concluded at the end of the inquest . The conclusion of the inquest was: � Antony WARING died on 24 June 2020 at Royal Blackburn Hospital following a highly inappropriate choice of urological surgical technique for the insertion of the suprapubic catheter causing perforation to the small bowel and resulting in a major laparotomy and admission to the Intensive Therapy Unit. Subsequent necessary feeding via a nasogastric tube in the oesophagus resulted in an aspiration pneumonia. Mr Waring�s death was contributed to by neglect. � 1a Aspiration pneumonia following inadequate placement of nasogastric tube; 1b Laparotomy for small bowel perforation and bladder repair; 1c Supra pubic catheter insertion. II Multiple Sclerosis	CIRCUMSTANCES OF DEATH Antony Waring was 71 years of age on the date of his death of 24 June 2020 at Royal Blackburn Hospital operated by East Lancashire Hospitals Trust. � In�� 2002�� Antony�� suffered�� from�� Multiple�� Sclerosis�� Waring�� had undergone a cystoplasty in which a loop of small bowel was brought down� into� the� pelvis.� There� was� a� second� laparotomy� due� to adhesions a week later. � On 20 March 2020 Antony Waring attended an Urology outpatient appointment for the insertion of a suprapubic catheter insertion, which was necessary due to complications caused by an indwelling catheter. For the insertion of a suprapubic catheter, Consultant 1 described Antony Waring�s insertion of a suprapubic catheter as a �difficult and risky� procedure due to the previous surgery. As a result, to manage this� risk,� Antony� Waring� was� listed� for� a� catheter� insertion� with ultrasound guidance. The only guidance available in Europe and North America concerning the insertion of suprapubic catheters published by the� British� Association of� Urological� Surgeons� guidance.� This is� a document by� a� committee that is subsequently� peer-reviewed� and consulted upon before being published in a journal. There is no NICE guidance for the insertion of suprapubic catheters. The 2010 BAUS guidance relevant at the time states as follows: � �In the patient with either a history of lower abdominal surgery or a bladder that� cannot� be adequately distended,� the� SPC should either be inserted using an open technique or with the adjunct of imaging that can reliably exclude the presence of bowel loops on the�� intended�� catheter�� track.�� An�� open�� procedure�� must�� be performed in a manner that will reliably identify the bladder and allow� mobilisation� of� any� interposing� intestine� away� from� the catheter track.� Consultant 1 informed Antony Waring that an open procedure was not in his best interests. Consultant 1 made no request for Antony Waring to be allocated to a urological consultant who use CT scanning, nor made� any� arrangements� for� the� presence� of� an� interventional radiologist� to� provide� ultrasound� guidance� and� allocated� Antony Waring to a Core List where it was a matter of chance if ultrasound guidance� would� be� used.� The� Trust� has� at� least� two� consultant urological surgeons who routinely use ultrasound. � On 12 June 2020 Antony Waring attended hospital for the insertion of a suprapubic catheter. Consultant 2 was aware of consultant 1�s views that� ultrasound� guidance� was� necessary.� Consultant� 2� made� no attempt to manage the increased risk of interposing bowel on the suprapubic catheter insertion track by arranging either ultrasound or undertaking an open procedure. Consultant 2 inflated Antony Waring�s bladder and inserted the suprapubic catheter perforating two loops of small bowel during the introduction. Antony Waring was admitted to intensive care unit with peritonitis and died 12 days later. � The�� adequacy�� of�� the�� Trust�s�� Maintaining�� Health�� Professional Standards investigation and adequacy of the consent process have been dealt with by separate correspondence.	COPIES AND PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � 1. Antony Waring�s family 2. CQC 3. Relevant ICB 4. British Association of Urological Surgeons � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.	Hospital Death (Clinical Procedures and medical management) related deaths� � This report is being sent to: East Lancashire Hospitals Trust
20/12/2024	2024-0705	Eleanor Curley-Bennett	Staffordshire	Festimed � Event Medical Provision Company.	On the 20 August 2023, I commenced an investigation into the death of Eleanor Curley-Bennett.� The investigation concluded at the end of the inquest on 9 December 2024. �The conclusion of the inquest was a narrative conclusion.� � The cause of death was: � � 1a) Positional Asphyxia	i) Eleanor Curley-Bennett, 3 weeks old, was in a baby carrier with her mother, on the 18 Augusdt 2023.� She was at a local, family friendly, music festival.� Her mother realised something was wrong and that Eleanor Curley-Bennett, has stopped breathing.� ii) She was taken to Festimed, who provided medical care for the music festival.� The carried out basic life support on Eleanor Curley-Bennett, before ad during the ambulance journey to the Princess Royal Hospital, Shropshire, where she passed away in the early hours of the morning the following day, the 19 August 2023.� iii) During evidence it was disclosed that Festimed did not carry the correct basic life support equipment, in the correct sizing for a baby of Eleanor Curley-Bennet�s age.� Specifically. a) oropharyngeal airway; b) i-gel airway; and c) Tracheal tube.� It was disclosed that there was no intubation equipment available.� It was disclosed that there were no prefilled, diluted, adrenaline that would be suitable to be used on a patient of Eleanor Curley Bennetts age.	I have sent a copy of my report to the family of Eleanor Curley-Bennett.� I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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)	Festimed
21/08/2023	2023-0303	David Celino	West Yorkshire (Eastern)	Festival Republic Ltd Leeds City Council FAO Chair of the Licensing Committee� West Yorkshire Police, [REDACTED] Rt Hon Suella Braverman KC MP, Home Office, FAO Secretary of State for Home Dept. Rt Hon Secretary Lucy Frazer KC MP, of State for Culture, Media and Sport	On 2 September 2022, I commenced an investigation into the death of David Joseph Celino aged 16. The investigation concluded at the end of the Inquest on 17 August 2023. The conclusion of the Inquest was a Narrative in which the medical cause of death was 1a Serotonin Syndrome, 1b MOMA intoxication. David Celino, aged 16, was sold tablets�[REDACTED] at the Leeds Festival in August 2022. Shortly after taking��[REDACTED] tablets, he developed symptoms. Despite prompt treatment, at the festival�s field hospital and in a hospital ICU, he could not be revived.	In August 2022, large numbers of people under the age of 18 were permitted to attend the three day outdoor music event known as the Leeds Festival. This admission policy was accepted by the Leeds City Council who licence the festival and had a statutory duty to protect children from harm and prevent crime. � The 2022 Crime Plan prepared by West Yorkshire Police acknowledged that the festival was targeted by gangs of criminals who seek to profit by supplying drugs to those attending. It was further acknowledged in this plan that young people under the age of 18 are likely to be naive to the risks relating to illicit drugs and hence, vulnerable to exploitation. � David J Celino and his 5 friends were in this potentially vulnerable group. They had little experience of illicit drugs. They were attending a music festival for the first time without adult supervision. They were excited, having just received their GCSE results on Thursday 25 August 2022. Their parents did not have sufficient information about the availability of and/or use of drugs at the festival to make an informed assessment of the risk to their sons. � David Celino bought three tablets from a drug dealer, represented to be [REDACTED]. He had no information concerning the composition of the tablets, their strength, the max dose to take (if such exists), nor the symptoms indicating an adverse reaction which should highlight the need to obtain urgent medical help. � He probably took [REDACTED] tablets and began to exhibit signs of an adverse reaction within the hour. He walked around the festival site for a�[REDACTED] approximately 90 minutes before collapsing and being taken to the onsite field hospital. The skilled clinicians there� realised his condition may prove fatal and so after initial treatment, expedited his transfer to hospital, where he died early the next morning.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � 1.��[REDACTED] (Parents) 2.�� Local Safeguarding Board � I have also sent it to the following individuals who may find it useful or of interest: 1.��[REDACTED], Yorkshire Evening Post 2. �[REDACTED], Yorkshire Live 3.��[REDACTED], ITV 4.��[REDACTED], PA Media 5.��[REDACTED], Bauer Media 6.��[REDACTED], BBC � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. � You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Child Death (from 2015) \| Alcohol, drugs medication related deaths This report is being sent to: Festival Republic \| Leeds City Council \| West Yorkshire Police \| Home Office \| Department for Culture, Media and Sport
19/06/2024	2024-0329	Chloe Hunt	Essex	Chief Executive Officer East Suffolk & North Essex NHS Foundation Trust NHS England	On 22 March 2022 an investigation was commenced into the death of Chloe HUNT, aged 21 years. Chloe Hunt died on the 15 March 2022. The investigation concluded at the inquest on 29 May 2024. The conclusion of the inquest was Narrative: �Chloe�s death was avoidable. Had the pens in the stomach and duodenum been removed earlier, Chloe would not have died when she did.� The medical cause of death of �1a Fatal Cardiac Arrhythmia Secondary to Metabolic Derangement due to Gastrointestinal Obstruction due to Pens in the Stomach and Duodenum	Chloe Hunt died on 15 March 2022 at Colchester General Hospital due to Fatal Cardiac Arrhythmia Secondary to Metabolic Derangement due to Gastrointestinal Obstruction due to Pens in the Stomach and Duodenum. Chloe had a history of severe trauma and self-harm and engaging in care and treatment to cope with complex trauma, self-harm and overwhelming thoughts. Chloe swallowed 4 pens (initially thought to be 3) and was admitted to hospital on 11 March 2022 with abdominal pain. A CT scan found 1 of the pens was impacted in her duodenum. Being in hospital was hard to tolerate for Chloe due to her trauma and she informed the consultant. Chloe was not referred for removal of the pens. Chloe had to go outside on 12 March and represented after a number of hours with increased pain. Further tests were completed in the emergency department. Chloe was not given the option of general anaesthesia with a surgeon on referral for removal. Chloe underwent gastroscopy under sedation on 14 March and 2 pens were removed. It was not possible to remove the impacted pen. Chloe could not continue to tolerate the procedure with reintubation on each removal for the other pen. The procedure then could not be converted to general anaesthesia in the interventional radiology suite. Chloe was referred to the surgeons and was due to undergo a procedure on 15 March 2022. The remaining pen in Chloe�s stomach also became impacted during the interval between the gastroscopy and her death. Chloe was last seen responsive around 03:45. Chloe had largely been tachycardic throughout her admission with low pressure and her oxygen saturations fell during the night requiring oxygen. Chloe had known previous overdoses and was found on post-mortem to have a thickened left ventricle in the absence of hypertension. Chloe was found in cardiac arrest at approximately 05:50 having suffered a cardiac arrhythmia secondary to metabolic derangement and resuscitation was not successful.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Care Quality Commission � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: East Suffolk and North Essex NHS Foundation Trust \| NHS England
19/12/2023	2023-0540	Morgan-Rose Hart	Essex	Chief Executive Officer Essex Partnership University NHS Foundation Trust Chief Executive Officer Essex County Council	On 26 July 2022 an investigation was commenced into the death of MORGAN- ROSE HART aged 18. The investigation concluded at the end of the inquest on 1 December 2023. The conclusion of the jury inquest was 1a Hypoxic Ischaemic Brain Injury 1b Cardiac Arrest 1c Ligature Misadventure Contributed by Neglect � Morgan-Rose Hart�s transfer to adult services was not supported enough with a clear transfer to ease her anxieties and worries. From the transfer to Chelmer ward Morgan-Rose�s medical history, diagnosis and triggers including her communication passport were not filtered down to staff who were tasked to providing her day-to-day care. Morgan-Rose�s known triggers and change in behaviour were not observed or documented whilst she was presenting behaviours of her mental health deteriorating. For example, doing her make up, spending more time alone and losing weight. Observations mainly being completed via the Oxevision system apart from the level 3 observations. There was limited therapeutic engagements or attempts to engage with Morgan-Rose. Staff observations being falsified led to Morgan-Rose not being checked and she felt staff did not have time for her. On the day of the 6th July 2022, critical observations were missed, Oxevision alerts were muted or reset without the correct procedures being adhered to, contributed to Morgan-Rose being left unattended in her bathroom for approximately 50 minutes after the Oxevision red alert was reset on display 01, in this time she tied a ligature around her neck. Morgan-Rose expressed she did not want to die but was high risk of self- harm and had a history of ligaturing. It was also documented Morgan-Rose was known to mask her behaviours. When reduced to Level 2 and Level 1 observations the correct risk assessments including room checks were not completed. Resulting in restricted items being easily accessed. This increased the risk of self-harm. The failure of basic protocol and procedure documented by Essex Partnership University NHS Foundation Trust resulted in Morgan-Rose Hart dying by Misadventure Contributed by Neglect.	Morgan Rose died on 12th July 2022 at the Princess Alexander Hospital, Hamstel Road, Harlow, Essex following being found unresponsive on the bathroom floor of her room. Morgan-Rose Hart was detained under section 3 of the Mental Health Act at the Derwent Centre on the female ward called Chelmer. Morgan-Rose had tied a ligature around her neck which resulted in a Cardiac Arrest and then Hypoxic Ischaemic Brain Injury. Morgan-Rose Hart was pronounced dead on the 12th July 2022 after brain stem testing confirmed Morgan-rose Hart had sustained Irreversible Brian Injury. On 6th July 2022 events contributed to Morgan-Rose�s mental health deterioration. Morgan-Rose was not observed clinically since 14:06 and the time in between the last observation and when Morgan-Rose was discovered multiple failings occurred. These include non-clinical and clinical staff commenting on her appearance, a delivery of flowers triggering a response, observation Level 1 missed the following hour, as well as the consecutive hours observations also being incorrect and falsified. Other events during the day triggered an emotional response clinical staff reflecting unescorted leave and no therapeutic engagement was made to see if Morgan-Rose was okay. After the delivery of the flowers incorrectly delivered to Morgan-Rose. Morgan- Rose attempted to contact relatives to clarify who these were from as there was some confusion as to who the flowers were for. The flowers were not meant for Morgan-Rose. Whilst Morgan-Rose was in the bedroom multiple attempts were made to interact with the Oxevision system to check vital signs, although the system could not access this due to the tile being Amber stating that Morgan-Rose was in the bathroom. Regardless of the Oxevision no member of staff attempted a physical welfare check until she was discovered unresponsive on the bathroom floor, in the shower, fully clothes at 16:20:37, confirmed on CCTV records. Staff proceeded to perform CPR and resuscitation until paramedics arrived at 16:27. Morgan- rose was left unattended for approximately 50 minutes prior to being found with the ligature around her neck. Morgan�s last physical check was at 14:06. Morgan-Rose had not had recorded observations for 2 hours and 14 minutes according to CCTV footage.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED] (Mother) [REDACTED] (Father) � I have also sent it to Care Quality Commission who 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 \| Suicide (from 2015) This report is being sent to: Essex Partnership University Trust \| Essex County Council
19/06/2024	2024-0331	Aaron Deeley	Essex	Chief Executive Officer Mid & South Essex NHS Foundation Trust � Chief Executive Officer Essex Partnership University NHS Trust � NHS England	On 25 February 2022 an investigation was commenced into the death of Aaron James DEELEY, AGE 43. The investigation concluded at the end of the inquest on 24 May 2024. The Jury�s conclusion of the inquest was 1a Multiple Traumatic Injuries with a Narrative: Aaron James Deeley came to his death by suicide contributed to by neglect on the 14th January 2022 at 01:58.We accept the admissions made by Mid and South Essex NHS Foundation Trust (MSE) as attached. However, in addition we consider probable, causative factors as follows; MSE had ample opportunities to make good or replace the windows, as the issues were first reported in April 2019 but had failed to do so by the time of Aarons� death. Notwithstanding a Section 5(2) of the Mental Health Act, Deprivation of Liberty Safeguards (DOLS) and Mental Capacity Act paperwork being in place, the security one to one (1:1) was removed, failing to meet Aarons� requirements for ongoing 1:1 supervision at circa 21:00 on 13/01/2022. In addition, we consider the following possible causative factors as follows; Insufficient administration and inadequate record keeping, incidents of these failures include: �� Inconsistencies in completion of the ward Enhanced Observation Form on 13/01/2022, Following Aarons� first suicide attempt the discharge paperwork of the Mental Health Liaison Team (MHLT) assessment on 02/12/2021 was sent to the wrong GP address, Discharge paperwork from Southend Hospital on 02/12/2021 was lacking sufficient detail of the intent and the overdose medication, Insufficient minutes recorded from the Essex University Partnership NHS Foundation Trust (EPUT) Multi-Disciplinary Team (MDT) on 21/12/2021, to understand the decision to decline the referral of Aaron to the First Response Team, On-going COVID restrictions impacting staffing and working environment during November 2021 to January 2022, Conflicting understanding of the policy regarding the intervention of the MHLT for patients on the Acute Medical Unit (AMU) ward.	Following several known suicide attempts, over the period November 2021 and January 2022, failings in the care and safeguarding provided by Mid and South Essex NHS Foundation Trust contributed to Aaron James Deeley being able to take his own life. On the 14th January 2022 at around 01:26 Aaron James Deeley took deliberate action to exit from the defective 2nd floor window next to his bed on Acute Medical Unit 1 ward at Southend Hospital. Landing on the ground below, Aaron sustained multiple traumatic injuries resulting in his death at 01:58.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Family of Aaron Deeley 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) \| Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Mid & South Essex NHS Foundation Trust \| Essex Partnership University NHS Trust \| NHS England
08/12/2023	2023-0511	William Gray	Essex	Chief Executive Officer Mid & South Essex NHS Foundation Trust�� [REDACTED] Chief Executive Association of Ambulance Chief Executives�� [REDACTED] Chief Executive East of England Ambulance Service NHS Trust Victoria Atkins Secretary of State for Health�� [REDACTED] Chief Executive Officer Essex Partnership University NHS Foundation Trust	On 9 June 2021 an investigation was commenced into the death of WILLIAM BRIAN KIN GRAY age 10. The investigation concluded at the end of the inquest on 22 November 2023. The conclusion of the inquest was 1a Cardiac Arrest Secondary to Respiratory Arrest 1b Acute Asthma Secondary to Chronically Very Under controlled Asthma. � William Gray died as a consequence of failures by healthcare professionals to recognise the severity and frequency of his asthma symptomatology and the consequential risk to his life that was obvious. William�s death was contributed to by neglect. William�s death was avoidable. There were multiple failures to escalate and treat William�s very poorly controlled asthma by healthcare professionals that would and should have saved William�s life.	William had a seven-year history of asthma and met the criteria for specialist referral. William�s care and treatment was sub-optimal; his asthma was poorly controlled in the absence of appropriate assessment and reviews. William required chest compressions and intramuscular adrenalin in accordance with the Joint Royal Colleges Ambulances Liaison Committee (JRCALC) Guidelines with oxygen for a life-threatening asthma attack on 27 October 2020 that saved his life. William was conveyed to Southend Hospital where he was discharged home four hours later with no assessment of his recent symptomatology and no change to his medications. Family contacted the GP service for advice and chased a referral to the asthma and allergy services. No changes were made to William�s medication until 4 November 2020 when he was prescribed a steroid preventer inhaler at the request of the asthma nurse and follow-up with Southend Hospital. William was lost to follow-up at Southend Hospital following a consultant appointment on 14 November 2020. The Asthma and Allergy Service comprised of telephone calls of no more than five minutes with no contact after 1 February 2021 until 21 May. The GP prescribed four short doses of oral steroids for exacerbations of his asthma in December 2020, February, April and 19 May 2021 that were insufficient to effectively manage obviously poorly controlled asthma in a picture of vastly excessive reliever inhaler prescriptions and the absence ongoing of preventer medication. On 21 May 2021 the asthma nurse did not review or escalate the increased salbutamol inhaler use information shared. The advanced GP nurse practitioner reviewed William�s condition on 25 May 2021 at the request of the GP following the final prescription of steroids and confirmed that William�s asthma remained very poorly controlled but failed to escalate concerns. As a consequence of multiple failures, William suffered an inevitable life-threatening asthma attack on the night of 29 May 2021 and crew arrived at approximately 00:18. Ambulance Crew could not secure William�s airway when he went into respiratory arrest with a missed opportunity by ambulance crew to administer intramuscular adrenalin in the presence of a strong pulse that probably would have delayed the cardiac arrest and possibly saved his life. William went into cardiac arrest at approximately 00:35 with further crew on scene and chest compressions commenced. Intravenous adrenalin was administered at approximately 00:45 when William was in the ambulance and resuscitation continued until HEMS met the ambulance en-route to hospital. The HEMS doctor inserted an endotracheal tube and administered medications and William was conveyed to hospital. William had sustained a brain injury not compatible with life.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: ��[REDACTED] (Mother) �� 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.	Child Death (from 2015) \| Hospital Death (Clinical Procedures and medical management) related deaths This report is being sent to: Mid and South Essex NHS Foundation Trust \| Association of Ambulance Chief Executives \| East of England Ambulance Service NHS Trust \| Department of Health and Social Care \| Essex Partnership University NHS Foundation Trust
22/12/2023	2024-0100	Barbara Woodman	Surrey	Chief Executive Officer NHS England Chief Executive Officer Surrey County Council Chief Constable Surrey Police Chief Executive Officer Surrey and Borders Partnership NHS Foundation Trust	On 8th July 2021 I commenced an investigation into the death of Barbara Ann WOODMAN. The investigation concluded at the end of the inquest on 18th October 2022. The inquest was heard without a Jury. � Ms. Woodman died of: 1a. Paracetamol, Codeine and Amlodipine Toxicity I returned the following narrative conclusion: Barbara Ann WOODMAN was admitted to the Abraham Cowley Unit under section on the 4th of March 2021 following an overdose on the 23rd of February 2021 which resulted in her emergency admission to Epsom General Hospital. She was initially guarded and did not engage with Spenser Ward staff seeking to provide her with care and treatment, although this subsequently improved during her period of inpatient care. The initial diagnosis of depression which had led to her section was determined inaccurate and a substitute diagnosis of personality disorder agreed, although additional work following her discharge was to be undertaken to identify the correct subcategory of personality disorder. � Ms. WOODMAN was discharged from section on the 18th of March 2021 and agreed to remain at the Abraham Cowley Unit as an inpatient for a further period of assessment. On the 25th of March 2021 she was assessed as fit for discharge to the community under the care of the Community Mental Health Team. A telephone conversation between Ms. WOOMAN and her Care Coordinator occurred on the 26th of March 2021. During this call the Care Coordinator assessed Ms. WOODMAN as not posing an escalated risk to herself. There was an interaction between Ms. WOODMAN and the Police on the 27th of March 2021 when police attended at her residence. No concerns were identified in relation to her risk to self except for the possible use of alcohol. A SCARF Report was raised by Police on the 27th of March 2021 in relation to this contact. It was passed to the Community Mental Health Team by Surrey County Council Adult Social Services on the 29th of March 2021. The SCARF Report was considered by Ms. WOODMAN�s Care Coordinator on the morning of the 31st of March 2021. � After several failed attempts to contact Ms. WOODMAN for a pre-arranged call on the 31st of March 2021, Ms. WOODMAN�s Care Coordinator visited her residence at around 16:30 hours to ascertain her whereabouts, posting a note through her letterbox when she could not contact Ms. WOODMAN. Following discussion within the Community Mental Health Team, Police were notified of a concern for Ms. WOODMAN�s welfare at 18:00 hours on the 31st of March 2021. Police attended Ms. WOODMAN�s residence at around 19:20 hours and having forced entry discovered Ms. WOODMAN deceased. No notes or other evidence indicating that Ms. WOODMAN had intended to take her life were found. � Post-mortem examination of Ms. WOODMAN�s body determined that she had died from Paracetamol, Codeine and Amlodipine toxicity. She had also consumed alcohol. It is not clear why Ms. WOODMAN consumed a fatal quantity of these drugs, and her death was drug and alcohol related.	The circumstances of the death are recorded in the Narrative Conclusion.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely: � Family of Barbara Ann WOODMAN [REDACTED] (Son) [REDACTED](Daughter) [REDACTED] (partner of Ms. WOODMAN) Surrey and Borders Partnership NHS Foundation Trust (SABP) Epsom General Hospital (EGH) Surrey County Council Adult Social Care (SCC ASC) � 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.	Alcohol, drug and medication related deaths This report is being sent to: NHS England \| Surrey County Council \| Surrey Police \| Surrey and Borders Partnership NHS Foundation Trust
26/06/2023	2023-0211	Keith Nielsen	Surrey	Chief Executive Officer South East Coast Ambulance Service (SECAMBS) 4 Gatwick Road Crawley Sussex RH10 9BG � Rt. Hon. Steve Barclay Secretary of State for Health and Social Care 39 Victoria Street London SW1H OEU	INQUEST An investigation into Mr Nielsen�s death was commenced on 30 March 2022 and an inquest was opened on 5 April 2022. The inquest resumed on 4 April 2023 and concluded on 13 April 2023. � The medical cause of Mr Nielsen�s death was: � 1a. Traumatic Brain Injury Causing Bi-Frontal Haemorrhagic Contusions 2. Anti-Coagulant Medication (Warfarin) due to previous Aortic Valve Replacement � The inquest concluded with a narrative conclusion as follows: � �Mr Nielsen was a 73 year old man who was prescribed the anti-coagulant medication Warfarin. On 20 March 2022 he sustained a head injury due to an unwitnessed fall at his home address. On the morning of 22 March 2022 Mr Nielsen was admitted to East Surrey Hospital and on 23 March 2022 he died at the hospital due to a head injury contributed to by his anti-coagulant medication which exacerbated the bleeding. At 05:33 on 21 March 2022 Mr Nielsen had made a 999 call reporting that he had fallen over and hit his head. South East Coast Ambulance Service (SECAMBS) did not send an ambulance due to a lack of available resources and Mr Nielsen was advised to make his own way to hospital. The 999 call was then closed with a �no send� disposition. However, Mr Nielsen did not make his way to hospital. Mr Nielsen�s 999 call was not suitable for a �no send� disposition because he was on his own with a suspected head injury and had reported a loss of consciousness for a significant period of time in the context of being on warfarin. Further, he had given no clear indication that he was going to make his own way to hospital. In the event that an ambulance had attended to take Mr Nielsen to hospital on 21 March 2022 he would have survived.�	On the morning of 21 March 2022 Mr Nielsen found himself on the floor at his home address and was unable to remember the previous twelve hours. At 05:33 Mr Nielsen called 999 and at some point that morning he also made an online request for a routine GP appointment. During the 999 call Mr Nielsen reported that he had fallen over and hit his head and could not remember the last twelve hours.� He also reported that he took Warfarin. The call handler triaged the call following the NHS pathway which resulted in a Category 3 ambulance response with a target response time of two hours. However, Mr Nielsen was advised to make his own way to hospital and the call was closed as a no send disposition. At 16:18 a GP at Medwyn GP surgery contacted Mr Nielsen by phone in response to his earlier online request for a routine appointment. The GP was not made aware of the fall or the head injury but given that Mr Nielsen was confused during the call and was on Warfarin he asked his receptionist to call an ambulance. At 17:37 a receptionist called and requested an ambulance within two hours. However, an ambulance did not attend until 07:22 the following morning at which time Mr Nielsen was found to be unresponsive. He was taken to East Surrey Hospital, where he was diagnosed with a traumatic brain injury and he died at the hospital on 23 March 2022. On 21 March 2022 SECAMBS was operating at Level 4 of its Surge Management Plan, meaning that demand for the service was significantly outstripping available resources and the service was not capable of responding to calls within target timeframes. The court heard evidence that SECMABS operates a no send policy during Level 4 of its Surge Management Plan whereby Category 3 patients are asked to make their own way to hospital. However, if they are unable to make their own way to hospital � or they refuse to do so � the call is subject to a clinical review and a decision is taken as to whether an ambulance should be sent out to the patient. During his 999 call, Mr Nielsen reported that he was alone, had hit his head and could not remember the last twelve hours. He did not agree to make his own way to hospital. Accordingly, the court found that a clinical review should have taken place which would have resulted in a category 3 ambulance being assigned to Mr Nielsen. In the event that a category 3 ambulance had been so assigned Mr Nielsen would have survived. Additionally, the court found that there was a significant delay in dispatching an ambulance following the GP surgery�s call to request an ambulance for Mr Nielsen, which was due to SECAMBS being in Level 4 of its Surge Management Plan. Whilst the length of that delay is clearly a matter of concern, it did not materially contribute to Mr Nielsen�s death. The court heard evidence from�[REDACTED] , Operating Unit Manager at SECAMBS, that the organisation is regularly operating at Level 4 of the Surge Management Plan. He gave evidence that the reasons were multi-factorial and, in particular, he highlighted insufficient staff being available to cover the required operational hours and lengthy delays in hospital handovers leading to a loss of operational hours.	COPIESI have sent a copy of this report to the following:�1.�� Chief Coroner 2. [REDACTED}3. [REDACTED]	Emergency services related deaths (2019 onwards) This report is being sent to: South East Coast Ambulance Service \| Department of Health and Social Care
26/06/2023	2023-0212	Ginger Wright	Surrey	Chief Executive Officer South East Coast Ambulance Service (SECAMBS) 4 Gatwick Road Crawley Sussex RH10 9BG � Rt. Hon. Steve Barclay Secretary of State for Health and Social Care 39 Victoria Street London SW1H OEU	INQUEST An inquest into the death of Mr Wright was opened on 5 July 2022. The inquest resumed on 22 May 2023 and concluded on 6 June 2023. � The medical cause of Mr Wright�s death was: � 1a. Quetiapine Toxicity � The inquest concluded with a narrative conclusion as follows: � �On the night of 14 June 2022 or the early hours of the morning on 15 June 2022 Mr Wright took a deliberate overdose of his prescribed quetiapine medication at his home address. At the time he took the overdose he intended to take his own life. After he had taken the overdose he spoke to a friend on the phone and allowed her to call an ambulance for him. He also propped the front door open so that the ambulance would be able to gain access on their arrival. However, on the arrival of the ambulance crew Mr Wright was found to be deceased. His death was due to quetiapine toxicity.�	In the early hours of the morning on 15 June 2022 Mr Wright�s friend [REDACTED] sent him a text message and Mr Wright called�[REDACTED] and told �[REDACTED] that he had taken �[REDACTED] quetiapine tablets and he wanted to die. managed to persuade him to let �[REDACTED] call an ambulance. � At 04:58�[REDACTED] rang 999 and informed the operator that Mr Wright was conscious and breathing but that he had taken an overdose. provided the details of what he had taken.��[REDACTED] Wright back and remained on the phone to him [REDACTED] the ambulance. At 05:26 �[REDACTED] thought that Mr Wright was now unconscious and she did not know if he was breathing or not. � At 06:40 an ambulance arrived at Mr Wright�s address and he was pronounced deceased at 07:39. � The court found that there was a delay from 05:10 onwards in carrying out an urgent clinical review of the first 999 call by staff at the Emergency Control Room at South East Coast Ambulance Service (SECAMB). Had a clinical review taken place at 05:10, the call would have been upgraded to a Category 2 call with a target response time of 18 minutes from the original call.� In fact, the call was not upgraded to a Category 2 call until [REDACTED] called back at 05:26, and thereafter an ambulance did not arrive at Mr Wright�s address until 06:40, one hour and 14 minutes later. � Whilst the above delays are clearly a matter of concern, the court was not persuaded that they materially contributed to Mr Wright�s death. � The initial delay at 05:10 was due to individual error and therefore does not form part of the concerns which you are asked to address in response to this report. � However, the subsequent delay, which occurred following the second 999 call at 05:26, was because SECAMBS was in Stage 4 of its Surge Management Plan, meaning that demand for the service was significantly outstripping available resources and the service was not capable of responding to calls within target timeframes. � During the inquest the court heard evidence from [REDACTED] Clinical Manager at SECAMBS Emergency Control Room. [REDACTED] gave evidence that during the last reported quarter, namely January to April 2023, SECAMBS had been operating at Stage 4 of its Surge Management Plan for 11.71 per cent of the time. In the previous quarter of September to December 2022, the Trust had been operating at Stage 4 for 45.73 per cent of the time. � [REDACTED] informed the court that there were various reasons for SECAMBS being in Stage 4 of the Surge Management Plan on such a frequent basis, including lengthy waiting times to hand patients over to hospitals, insufficient staff numbers despite efforts to recruit both here and abroad, as well as high numbers of staff sickness. � Whilst the reported figures indicate a notable reduction in the amount of time SECAMBS is spending in Stage 4 of the Surge Management Plan as compared with the latter half of 2022, it remains a matter of significant concern that the Trust is unable to respond to calls within target timeframes for 11.71 per cent of the time.	COPIES I have sent a copy of this report to the following: � 1.�� Chief Coroner Mr Wright�s family	Emergency services related deaths (2019 onwards) \| Alcohol, drugs medication related deaths \| Suicide (from 2015) This report is being sent to: South East Coast Ambulance Service \| Department of Health and Social Care
18/09/2024	2024-0498	Helen Kerr	Surrey	Chief Executive Officer Surrey County Council�� Chief Constable Surrey Police�� Chief Executive Surrey and Borders Partnership	On 24th April 2023 an investigation into the death of Helen Jane Kerr was� commenced. The investigation concluded at the end of the inquest on 7th June 2024.�� Helen Kerr died by hanging.�� The conclusion as to death was a narrative conclusion as follows:� Helen Kerr went to live at in a refuge in Woking on the 2nd February 2023. She had a history of drug and alcohol abuse and was referred to I access. Her mental health deteriorated, and she developed psychosis.�� On the 1st March 2023 she was assessed at I access and a plan for a referral to the community health team was devised. The referral was not made because of� pressure of work.�� On the 13th March 2023 her support worker was so concerned by her mental�health that she called an ambulance and Helen was taken to St Peter�s Hospital.� She was seen by a nurse from the liaison psychiatry team. No collateral information was sought and the full description of her presentation from the paramedics was�not seen. She was assessed as not requiring a referral to the community mental� health team despite showing signs of paranoid delusions. She was discharged.� Her support workers made repeated attempts to obtain mental health care for�Helen contacting the single point of access, I access, the community mental health and the CRISIS line. Helen�s case was not discussed with a psychiatrist and her� support workers were not contacted for information by any of these organisations.� On the 31st March 2023 Helen attended Surrey Police station in an extremely� paranoid state and then went to St Peter�s Hospital seeking an admission. She was partially assessed by liaison psychiatric nurses and offered a home treatment team� assessment. She declined and was discharged by the team without collateral� information being sought or the advice of an on-call psychiatrist. She needed to be� admitted to hospital for a diagnosis and treatment of her mental health condition.�� She was discharged from hospital on the 2nd April 2023 and returned to the refuge. She was found dead on the morning of the 3rd April 2023 having self-ligatured. Her� condition was amenable to treatment with anti-psychotic medication. The death�was avoidable with appropriate treatment. She intended to take her own life.� She died by suicide.�� The death was contributed to by neglect.	See the details set out in the narrative conclusion. In addition: Prior to being placed in the refuge on the 2nd February 2023 Ms Kerr was charged with� carrying a bladed article when she surrendered to bail. She told the police that she was carrying a knife for her own protection.�� This was known to Surrey Police and mental health services by March 2023. On the 13th March 2023 paramedics contacted the police for assistance at the refuge concerned because she was carrying a nail file for her own protection.� When she attended Surrey Police station on Friday the 31st March 2023 she did so� concerned for her own safety. She was extremely paranoid but was assessed not to warrant s136 detention. She left the police station saying she was going to hospital. A SCARF was written but could not be lodged before the end of the working day on the 31 March 2023. As a result, it was not processed until Monday the 3rd April 2023, after her death, because SCARF�s are processed during working hours.� The expert gave evidence was that she would have been very worried if she was told Ms� Kerr was carrying a knife because she was having paranoid delusions that she needed to protect herself and her family.�� Some of Ms Kerr�s paranoid delusions related to concerns about the actions refuge� workers. The refuge was not contacted by the police on the 31st March 2023. The court� was told that GDPR prevented the police from sharing the information about Ms Kerr with the refuge.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:� Mrs Kerr�s Family�� St Peter�s Hospital�� The Refuge (details redacted)�� I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.� I may also send a copy of your response to any other person who I believe may find it useful or of interest.� The Chief Coroner may publish either or both in a complete or redacted or summary� form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response.	Suicide (from 2015)�\| Mental Health related deaths	Surrey County Council \| Surrey Police�\| Surrey and Borders Partnership
15/01/2024	2024-0024	Nadia Wyatt	Essex	Chief Executive Officer of Essex Partnership NHS Trust, [REDACTED] Essex Partnership University NHS Foundation Trust, The Lodge, Lodge Approach, Runwell, Wickford, SS11 7XX	On 4 August 2023 I commenced an investigation into the death of Nadia Wyatt, 53. The investigation concluded at the end of the inquest on 8 January 2024. The conclusion of the inquest was suicide.	Nadia was a 53-year-old woman who had been struggling with issues affecting her mental health, namely severe anxiety, separation anxiety and depression initially in 2014 and then again from May 2023. Her separation anxiety had become so severe that it also began to impact her husband and his ability to leave her alone for any significant length of time and carry out his own work. She saw her GP on 16 and 30 June, and on 30 June she was referred to the Crisis Response Team. On both 5 and 8 July, she left a note for her family and took a taxi to a train station and multi-storey car park respectively. On each of those occasions, Nadia was found by police and taken to hospital. From 10 July she received specialist in-patient care at the Peter Bruff Unit, before being discharged home on 17 July under the care of the Crisis Home Treatment Team, who attended upon her either in person or virtually until 25 July. From 23 July she began to reach out to other professional colleagues (she had been a counsellor herself) via text message and email and made desperate pleas for help, to such an extent that one of these professionals called the police. On 26 July she recorded a video message for her daughter and left a handwritten note for her husband and daughter. She took sleeping tablets and appeared to have drunk some wine as well. When her husband returned home that evening, he found her hanging [REDACTED]. A post-mortem examination confirmed the medical cause of death to be; 1a Hanging. The toxicology report was consistent with medication that Nadia had been taking, both prescribed and over the counter remedies. Despite a clear desire to want to get better, intervention from professionals and the	I have sent a copy of my report to the Chief Coroner and to Nadia�s husband, [REDACTED] I have also sent it to The Care Quality Commission, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) This report is being sent to: Essex Partnership NHS Trust
23/12/2024	2024-0708	William Hare	Essex	Chief Executive Officer of Mid and South Essex NHS Foundation Trust, [REDACTED]	On 8 February 2024 I commenced an investigation into the death of William Charles�Hare (Bill), 71. The investigation concluded at the end of the inquest on 3 December 2024. � The conclusion of the inquest was a narrative conclusion outlining that Mr Hare had�died from metastatic urothelial cancer, contributed to by neglect, namely delays to� diagnosis and treatment resulting in the cancer spreading to such an extent any�treatment that could have been given, became futile.	Bill presented to Basildon Hospital in November 2022 with abdominal and left loin pain. Following CT scans and discussion at a Multi?Disciplinary Team (MDT) meeting, it was� suspected that Bill had cancer in the middle?left ureter. The MDT determined that an�MRI and CT chest be carried out as well as a consultation with Bill.� The MRI showed no obvious urothelial lesions and so the advice was that if concerns�remained, a ureteroscopy was recommended. Following a consultation with Bill on 4�January 2023 a ureteroscopy was requested. This was undertaken on 16 February. The results of the biopsy were available on 7 March but were inconclusive.� The MDT considered next steps on 21 March and advised that imaging and biopsy be repeated with a view to a nephroureterectomy being undertaken. A telephone� consultation took place with Bill on 27 March and he was referred to a Consultant�Urological Surgeon. Bill was not seen until 23 May.� The Consultant adopted the plan set by the MDT, although he felt that Bill would� ultimately require surgical intervention. A CT scan was repeated on 5 June but it�wasn�t until 29 August that Bill�s case and ongoing plan was next reviewed by the MDT. No one giving evidence could explain that delay.� Bill attended a pre?assessment clinic on 4 September, but due to an elevated HBA1c of 104 he was deemed unfit for surgery and instructions were given that he was to be�seen in the Diabetic Clinic and re?referred when his HBA1c was below 70.� In the meantime, Bill presented to Basildon hospital again on 3 October with�hyponatremia secondary to diarrhoea and hyperglycaemia secondary to poorly�controlled diabetes. His left kidney showed very poor function.� There was no evidence of bone metastasis. He was discharged on 25 October.� However, he presented again on 17 November with low sodium and sepsis with a left� nephrostomy tube. Further scans and investigations were undertaken but no positive action was taken in progressing Bill�s diagnosis or treatment plan.� By the time an MRI was undertaken on 20 December, there was evidence of disease progression.� Bill was due to be moved to Southend Hospital for specialist treatment by the renal team during this admission, however, due to a combination of a lack of beds, ward� closures, junior doctor strikes, a full ITU and issues with transport, he remained in�Basildon until 3 January 2024.� By this time, his cancer had metastasised to his bladder and psoas muscle. A further CT scan, the results of which only became available on 15 January, revealed that it has also spread to his lungs. Treatment had become futile.� Bill was placed on an end?of?life care plan and moved to a hospice where he passed away on 23 January.	I have sent a copy of my report to the Chief Coroner and to Bill�s family. I have also sent it to The Care Quality Commission, who may find it useful or of interest.� Further, I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary�form. He may send a copy of this report to any person who he believes may find it�useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief�Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths	Mid and South Essex NHS Foundation Trust
28/02/2024	2024-0111	Chloe Tapp	Essex	Chief Executive Officer of Mid and South Essex NHS Trust, [REDACTED]� NHS England	On 21 October 2021 I commenced an investigation into the death of Chloe Anne Tapp, 20. The investigation concluded at the end of the inquest on 9 February 2024. The conclusion of the inquest was natural causes.	Chloe was a 20 year-old girl with a medical history including microcephaly, an underdeveloped heart and epilepsy. She first began experiencing seizures at only a few months old. She was formally diagnosed with epilepsy when she was two years old and began taking sodium valproate to treat it, eventually moving to dual treatment with lamotrigine. She had been under the care of a paediatric consultant neurologist, but on turning 18, needed to be transferred to an adult consultant neurologist. There was a significant delay in this transition, and she did not see an adult consultant neurologist until September 2021. Chloe received an appointment for 3 September 2021, this took place over the phone despite Chloe being non-verbal. The consultation, therefore, was with her mother and there was no ability for the consultant to visually assess Chloe or her tremors. The consultant felt Chloe�s tremors were likely related to her prolonged use of sodium valproate and as a result agreed a plan to taper Chloe�s medication so that she was only taking lamotrigine. The plan needed to be gradual due to the risks associated with use of these two drugs at higher doses. There is a difference of opinion as to how this change would be affected and who was to implement it; the evidence led me to prefer Chloe�s mother�s account of the consultation. On request, a handwritten tapering regime was sent out to Chloe following the consultation explaining the changes that her mother was to implement. She was advised to call the neurology department if she had any queries or concerns. The tapering regime was complicated, and Chloe�s mother wanted to ensure that she had understood it correctly. Several attempts to call the neurology department were unsuccessful. The regime was also, in fact, incorrect; it had been based upon an assumed dose of the medication that Chloe was taking; Chloe�s medication was in millilitres as she had a liquid diet through a feeding tube, however, the consultant was unfamiliar with millilitres and usually worked with milligrams. She looked up the �usual� dose on the BNF and based the tapering regime on that. � The consultant�s account was that she had in fact adjusted the regime later in the consultation upon realising that Chloe was on higher doses than assumed, but neither a copy of the original nor the amended regime were entered onto Chloe�s records. On 22 September 2021 Chloe had an unwitnessed fall and from her body language appeared to have hurt her right leg. � On 6 October 2021 Chloe was still suffering with her leg and had a productive cough. Her mother took her to the Emergency Department; her chest x ray was clear but infection markers in her blood were slightly elevated. She was given antibiotics as a precautionary measure for her chest, analgesia and paracetamol and discharged. On 7 October 2021 around 1am Chloe suffered a tonic clonic seizure, an ambulance was called and in the meantime her mother administered emergency medication, shortly after Chloe suffered a further seizure and then stopped breathing. Her father followed advice from the emergency services and administered CPR. � An ambulance arrived at 1.26am. Chloe was unresponsive and in respiratory arrest. It was noted that multiple suctioning was required due to vomit and saliva and she had a temperature of 40. She then suffered a cardiac arrest. � One of the doctor�s treating Chloe was of the opinion was her high temperature had developed as a result of the dramatic seizures she experienced, rather than due to separate infection; her chest scan the day before was clear and infection makers only slightly raised and in addition, her temperature was 36.5 by the time she was admitted to the emergency department. � Chloe was admitted to hospital in the early hours of 7 October2021; her chest x ray showed bilateral pleural effusions. Ultimately the efforts of all those caring for her were unsuccessful and she passed away on 8 October 2021. � An independent consultant gave evidence that whist Chloe could have had a subtle chest infection on 6 October, this would not have been enough to overwhelm her in the manner that occurred on 7 October. However, being unwell may have been a trigger for the seizure, particularly as there appeared to have been an extended period of her requiring antibiotics for infections. � They did not consider that the medication change more than minimally contributed to her seizure or her death; the seizure could have occurred without any of the changes or triggering factors. � The cause of death was established on the evidence as �1a Epilepsy and pneumonia�. Chloe�s death was therefore from natural causes.	I have sent a copy of my report to the Chief Coroner and to the following interested persons: � Chloe�s parents�[REDACTED] [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: Mid and South Essex NHS Trust \| NHS England
07/10/2024	2024-0535	James Agius	Essex	Chief Executive Officer of North East London NHS Foundation Trust	On 4 January 2022 an investigation was commenced into the death of James Warren Agius aged 42. The investigation concluded at the end of the inquest on 4 October 2024. The conclusion of the inquest was Suicide with a medical cause of death of1a Suspension by Ligature.	James Agius was found deceased at home on 17 December 2022 on a welfare check, [REDACTED]. Mr Agius had a mental health disorder and severe complex trauma and was undergoing trauma therapy. There was a history of previous suicide attempts and self-harming and substance misuse for which he sought assistance from the mental health team. Mr Agius appeared to read a phone message on the morning of 17 December 2022 but had not responded. Mr Agius suspended himself on 17 December 2022 and intended the outcome to be fatal.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Family of Mr Agius. I have also sent it to the Care Quality Commission who may find it useful or of interest. � I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.	Suicide (from 2015) \| �Mental Health related deaths	North East London NHS Foundation Trust
21/04/2023	2023-0129	Amy Henderson	Surrey	Chief Executive Officer of The Priory Group Chief Executive Officer if NHS England	An inquest into the death of Miss Amy Henderson was opened on the 26th April 2022 and resumed with a jury on the 6th February 2023. The inquest was concluded on the 23rd February 2023. Evidence in respect of matters pertaining to this report was heard on the 20th March 2023. � The jury concluded that Miss Henderson died on the 21st March 2022 at the Priory Hospital, Woking and the medical cause of her death was: � 1a Suspension � They concluded with a narrative conclusion and found that: � 1. The Priory staff knew Amy had suicidal ideation, but they did not know any details concerning plans, or that she had practised tying a ligature. 2. No-one at the Priory asked her family about her suicide plans. 3. It is not possible to determine what Amy would have said to her consultant if she had been asked about suicide plans. Amy denied having any plans when asked by an HCA and she denied having thoughts of suicide in her 1:1 with a SHCA. 4. If Amy�s mother had been asked, she would have shown the screen shots from Amy�s phone and given details of Amy practising tying ligatures. Amy�s mother has no recollection of volunteering the information. 5. Despite the notes from the therapy sessions being uploaded at 16.06, there was no formal request for Amy to be reviewed. There is evidence from professionals that Amy should have been reviewed urgently on the basis of the notes, if they had been scrutinised. 6. If information about Amy practising tying a ligature had been known, there would have been more consideration given [REDACTED] bearing in mind the balance of risk and least restrictive practice. 21st March. Amy was generally compliant with staff, [REDACTED].� 7.� After the identification of the disabled toilet as a high-risk area in 2021, the ligature risk of the disabled toilet was not effectively managed although the Priory considered that it was. 8.� Amy had unrestricted access to the disabled toilet, which was accessible to all patients, staff and visitors. 9.� The Jury was not able to make a finding as to whether Amy was alive between 19.35 and 19.47. � In summary the following facts, on the balance of probabilities, made a material contribution to Amy Henderson�s death: a.� Risk Assessments were not performed in line with Priory policy. b.� There was no Key Worker present throughout Amy�s stay. c.� There were incomplete observations and little evidence of engagement with Amy during observations. Boxes were not ticked on Observation and Engagement Records. d.� The family was not consulted or questioned about Amy�s Suicide Plans. e.� Therapy notes were not acted upon. f.� There was a lack of staff training in Postnatal depression. g.� There was a lack of continuity of care. h.� The disabled toilet was not locked. i. Staff knowledge of the ligature footprint was inconsistent. � Amy committed suicide. She used a�[REDACTED] ligature and intended to kill herself. She is shown on CCTV entering the disabled toilet and no-one else entered it until Amy�s body was discovered. The death was contributed to by Neglect	Miss Henderson had a baby in 2021. When her baby was 11 months old she returned to work, but was signed off sick suffering from anxiety and depression. On the evening of the 14th March 2022 she was taken by her family to Kingston Hospital and assessed by the liaison psychiatric team. She expressed suicidal thoughts and plans [REDACTED]. � She was diagnosed with postpartum depression. She was advised to become an informal patient in the NHS but there was no bed available so she would have had to wait in the hospital until a bed could be found. She decided to seek a private admission the following day. � On the 15th March 2022 she sought treatment at the Priory Hospital, Woking. She had a preadmission assessment with [REDACTED] a consultant psychiatrist who accepted her as a patient. She told him that she had a suicide plan but did not provide details of what it was. He assessed her as a high risk of suicide and set observations at four times an hour. She was allocated a Key Worker who was not due to be in the hospital until 22nd March 2022, and a Co-worker, who had a one-to-one with her on 19th March 2022. Her overall mental health appeared to have improved when she was reviewed by [REDACTED] on March 18th 2022. The observation level was reduced to twice an hour on the 16th March 2022, and then further to once an hour on the morning of March 21st 2022, on each occasion without a risk assessment being performed as specified in the Priory policy. � Later on the morning of the 21st March 2022 Miss Henderson made comments during a therapy session which indicated that her mental health was deteriorating. The therapists recorded what she had said in her notes, but the concerns were not considered to be serious enough to be escalated to the nursing team. Evidence presented to the inquest suggests that Amy�s observations should have been increased at this stage. Amy was not reviewed by the nursing team when the therapists� notes were uploaded onto the system at 16.06 on 21st March 2022. The information was not reviewed and therefore not acted upon. � Miss Henderson was last seen in person at 18.02 in the dining room. At 18.12. she entered the downstairs disabled toilet. The disabled toilet had been identified in risk assessments as a high-risk area but it was not locked. She wrote a farewell note to her parents at 18.14. She was found in the disabled toilet on the ground floor at 20.01. She had taken her own life by suspension, [REDACTED].	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: � Miss Henderson�s family The Priory Woking [REDACTED] The Care Quality Commission � I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. � I may also send a copy of your response to any 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: The Priority Group and NHS England
29/12/2023	2024-0118	Meghan Chrismas	Surrey	Chief Executive Officer, NHS England Chief Constable Hampshire and Isle of Wight Constabulary	On 26th October 2021 I commenced an investigation into the death of Meghan Irene CHRISMAS. The investigation concluded at the end of the inquest on 24th April 2023. The inquest was heard with a Jury. � Mrs. CHRISMAS died of: 1a:�� Hypoxic Brain Injury 1b:�� Cardiac Arrest (Resuscitated) 1c:�� Hanging � The jury returned the following narrative conclusion: � Narrative conclusion � On 18th February 2021, Mrs. CHRISMAS had a face-to-face appointment with her GP, after which 50mg of the anti-depressant Sertraline was prescribed. Mrs. CHRISMAS suffered a panic attack on 4th July 2021 whilst out with friends for which an ambulance was called. On 7th July 2021, Mrs. CHRISMAS was referred to a private psychiatrist who admitted her voluntarily to the Priory, Roehampton after a new patient assessment. Mrs. CHRISMAS had two consultations with the private psychiatrist before electing to discharge herself from the Priory on 16th July 2021. Following this discharge, Mrs. CHRISMAS continued to meet with the private psychiatrist and received prescriptions from both the private psychiatrist and her GP, meaning that Mrs. CHRISMAS had access to double prescriptions. Mrs. CHRISMAS also commenced Eye Movement Desensitization and Reprocessing (EMDR) Therapy on 9th August 2021 with a separate private mental health practitioner. � On 1st October 2021, Mrs. CHRISMAS impulsively attempted suicide by overdose and was admitted to Royal Surrey Hospital on the following day. Mrs. CHRISMAS was offered further psychiatric treatment through the NHS at this time, which she declined in favour of continuing with her private treatments. On 4th October 2021, Mrs. CHRISMAS�s GP received a letter from Surrey and Borders Partnership�s psychiatric liaison service concerning her attendance the previous day. This letter was passed on to neither the private psychiatrist nor the EMDR therapist who were treating Mrs. CHRISMAS. Healthcare professionals treating Mrs. CHRISMAS placed significant reliance on the perception that she would be open and honest in her communication with them. � Following concerns expressed to Mrs. CHRISMAS�s GP by her husband, on 12th October 2021, the GP made an urgent referral to NHS Mental Health Services, which was ultimately rejected on the basis that Mrs. CHRISMAS had capacity and had not provided consent to be referred. � On 18th October 2021, Mrs. CHRISMAS had an outpatient appointment with her private psychiatrist who reported that Mrs. CHRISMAS was progressing well. After checking into the Premier Inn, Guildford, Mrs. CHRISMAS expressed in a WhatsApp message to her husband that she planned to hang herself. Shortly thereafter, her husband called 999 to report his concerns. At 16:54, Mrs. CHRISMAS contacted Surrey Police to explain that she was fine and in Guildford, although she gave no further details with respect to her location. � The incident regarding Mrs. CHRISMAS was initially logged as a Grade 1 Missing Person; however, according to the Hampshire Police control room logs there appears to have been some confusion with respect to risk status. Police officers acted under the impression that the incident was indeed high-risk, but the log describes the risk status as low. On the basis of this information, the handler in the control room decided to communicate with Surrey Police via email rather than by telephone at 17:18, which was inappropriate in light of the reality of the incident. It could not be concluded that this shortcoming significantly shortened the life of Mrs. CHRISMAS. � By 18:15, there had been no response from Surrey Police, at which point the handler communicated via telephone. Police officers arrived at [REDACTED], Guildford at 18:37 and sought access to the room in which Mrs. CHRISMAS was staying; however they found the room to be barricaded. Upon gaining access to the room, officers found Mrs. CHRISMAS suspended [REDACTED]. Attempts were made to resuscitate Mrs. CHRISMAS, resulting in the restarting of her heartbeat. After resuscitation, Mrs. CHRISMAS was transported to Royal Surrey County Hospital where she died two days later on 20th October 2021 from a Hypoxic Brain Injury. � Meghan Irene CHRISMAS took her own life whilst suffering from the diagnosed illnesses of Generalised Anxiety Disorder, Depression, Attention Deficit Hyperactivity Disorder and Complex Post Traumatic Stress Disorder.	The circumstances of the death are recorded in the Jury�s Narrative Conclusion. CORONER�S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. The concerns raised were as follows: a. Passage of information between NHS and private healthcare providers. At a time where pressures on the NHS exist, particularly for mental health services, it is of concern that measures which could alleviate this pressure (where someone sources private care) do not exist. There is little or no policy, guidance or other effective arrangements to share important clinical information about patients between private and public healthcare sectors. b. The handling of the incident involving Mrs. CHRISMAS in Hampshire Constabulary�s Force Control Room which resulted in a hour delay in determining that an important communication (being a request for assistance) had not been received by a neighbouring force. This raises concerns as to the effectiveness in the supervision of operators handling the calls and the presence of redundancies or safeguards to detect such circumstances sooner to avoid repetition. I received further evidence orally and in writing from the Interested Persons� subsequent to the completion of the Inquest in relation to these concerns. This evidence included responses from Surrey and Borders Partnership NHS Foundation Trust (SABP), The Priory Hospital, [REDACTED] concerning the measures which have been put in place to address the concerns identified during the course of the Inquest with respect to sub-paragraph a. (above). I was satisfied that these measures addressed the concerns in relation to each of those Interested Persons. In addition, I received evidence from Hampshire Constabulary concerning the measures which have been put in place to address the concerns identified during the course of the Inquest as outlined at sub-paragraph b. (above). These measures included: a. Revision of training provided and the introduction of additional training for supervisors and control room staff. b. Implementation of National Policy concerning Missing Persons, including documentation to assist in control room responses to similar circumstances. c. Revision of the recording of risk assessment measurements on the computer aided dispatch record (CAD) system. It was further explained to the court that the measures should be seen in the context of wider cultural change management in the supervision and leadership being undertaken by Hampshire Constabulary in the operation of the Control Room. I have taken account of the measures, many of which are of a policy nature, as outlined by Hampshire Constabulary. However, I remain concerned in relation to the matters identified at sub-paragraph b. (above). In addition, I am concerned that, although welcoming the local changes implemented by the Grayshott Surgery Practice, The Priory Roehampton and SABP, there is an absence of a wider national structure within the NHS that facilitates the effective passage of patient information between the private and public healthcare sectors. � In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. � The MATTERS OF CONCERN are as follows. � The effectiveness in the supervision of operators handling calls in the Hampshire Police Force Control Room to detect circumstances such as those which involved Mrs. CHRISMAS sooner and to avoid repetition. Evidence of the change required in this respect, was not provided to the court beyond limited training measures; either in the form of a plan to bring such change about, or evidence that such change has otherwise occurred. � The passage of information between NHS and private healthcare providers is hindered due to the absence of an adequate structure to share important clinical information about patients in a timely and effective manner.	29th December 2023�� Darren Stewart OBE	Suicide (from 2015) This report is being sent to: NHS England \| Hampshire and Isle of Wight Constabulary
25/10/2024	2024-0592	George Kyriacos Petrou	Inner North London	Chief Executive Officer� Barnet, Enfield and Haringey Mental Health NHS Trust Block 2B� St Ann�s Hospital� St Ann�s Road� London� N15 3TH	On 19 March 2021, an investigation was commenced into the death of� George Kyriacos Petrou, then aged 56 years. The investigation concluded at the end of an inquest heard by me between 30 September 2024 and 11� October 2024.� The inquest concluded with a short-form conclusion of suicide. The medical cause of death was:� 1a partial suspension	CIRCUMSTANCES OF DEATH George Petrou was remanded in custody on 21 March 2019 at HMP� Pentonville, pending a trial at the Crown Court. He was convicted of multiple offences in late 2020. On 26 February 2021, Mr Petrou was sentenced to 22 years� imprisonment via a video link hearing. Mr Petrou left the hearing prior� to hearing his sentence being handed down by the Judge.� Throughout 2019 and 2020, Mr Petrou had been placed on an �ACCT�� (suicide prevention measures) on four separate occasions. He had profound mental health concerns dating back many decades, which included a long� history of depression, previous self-harm and past attempts at suicide.� During his time in HMP Pentonville, there was no evidence that Mr Petrou� had self-harmed or made previous attempts at suicide. He was received care in relation to his physical health and was under the care of the mental health� in-reach team (provided by Barnet, Enfield and Haringey Mental Health NHS� Trust (the Trust)).� Receiving a long custodial sentence was a potential matter of concern for George Petrou. He was seen by staff from the Trust on the day of his� sentencing hearing and the following day.� Mr Petrou was found deceased in his cell at HMP Pentonville on 1 March� 2021, having partially suspended himself by ligature in the bathroom of his cell.	I have sent a copy of my report to the Chief Coroner and the following: REDACTED � Mr Petrou�s daughter Hudgell Solicitors (REDACTED) � solicitors acting on behalf of Mr Petrou�s family Practice Plus Group � primary care provider at HMP Pentonville Ministry of Justice / HMP Pentonville Care Quality Commission Prison and Probation Service Ombudsman I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.	Mental Health related deaths \| State Custody related deaths	Barnet, Enfield and Haringey Mental Health NHS Trust
03/12/2024	2024-0668	Mnayea Al Basman	Inner North London	Chief Executive Officer� Royal Free London NHS Foundation Trust Pond Street� Rosslyn Hill� London� NW3 2QG	On 3 April 2024, an investigation was commenced into the death of Mnayea ZMF Al Basman, aged 72 years at the time of his death. The investigation� concluded at the end of an inquest heard by me on 6 November and 3� December 2024.� The inquest concluded with a short narrative conclusion in the following�terms. �known complication of necessary surgical procedure�. The medical cause of death was:� 1a intra-abdominal sepsis / peritonitis� 1b anastomotic leak at site of right hemicolectomy�� 1c caecal adenocarcinoma (operated)� II end-stage renal failure, atherosclerosis, congestive cardiac failure	CIRCUMSTANCES OF DEATH Mr Al Basman had an extensive past medical history and significant� underlying co-morbidities. He was admitted to the private patient unit at the� Royal Free Hospital on 11 March 2024, to undergo a right hemicolectomy to excise a caecal adenocarcinoma, planned for the following day.� Mr Al Basman�s co-morbidities increased his general and specific surgical risks, but he was found to be fit to undergo the surgery.� The surgical procedure itself was �technically challenging� but otherwise� uneventful. Mr Al Basman showed signs of reasonable post-operative� recovery until the weekend of 23/24 March 2024. From 24 March 2024, he� deteriorated suddenly. Some aspects of his condition and clinical� presentation that weekend should have been escalated to the consultant� surgeon in charge of his care but were not; however, it is not possible to say that earlier escalation would have altered the outcome.� On Monday 25 March 2024, Mr Al Basman deteriorated further and died in hospital. Mr Al Basman�s death was the direct result of sepsis/peritonitis� caused by an anastomotic leak at the site of the right hemicolectomy.� Anastomotic leak is a known complication of this surgical procedure.	I have sent a copy of my report to the Chief Coroner and the following: Mr Al Basman�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. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths	Royal Free London NHS Foundation Trust
30/09/2024	2024-0517	Sophie Dean	Inner North London	Chief Executive Officer� University College London Hospitals NHS Foundation Trust 2nd Floor Central� 250 Euston Road� London� NW1 2 PG	On 22 September 2023, an investigation was commenced into the death of� Sophie Ann Dean, then aged 18 years. The investigation concluded at the�end of an inquest heard by me on 11 June, 16 September and 20 September 2024.� The inquest concluded with a short narrative conclusion in the following� terms, �complications following recent surgical procedures�. The medical cause of death was:� 1a disseminated intravascular coagulation and septicaemia�� 1b pneumonia� II�laparotomy (24 August 2023), re-closure of abdomen (4 September 2023), microcephaly, bilateral frontal polygyria	CIRCUMSTANCES OF DEATH Miss Dean had an extensive past medical history and significant underlying� co-morbidities. She was admitted to University College Hospital (UCH) on 23 August 2023, when air had been evidenced on a follow-up x-ray in relation to previous spinal surgery undertaken elsewhere.� Miss Dean underwent a CT scan of the abdomen and pelvis at UCH, which� showed �free air� in the abdomen. There were three possible causes of this:� 1) a duodenal ulcer; 2) a perforated bowel; and 3) a leak from Miss Dean�s�feeding tube. The view of the non-UCH radiology team who reported the scan overnight was that the most likely cause was Miss Dean�s feeding tube.�� The consultant surgeon on call discussed the scan with the UCH radiology� team, who were not sure of the underlying cause. The surgeon considered� that the cause was unlikely to be a leak from the feeding tube and was more�likely due to bowel perforation, which had a much greater potential to become a medical emergency.� On 24 August 2023, Miss Dean underwent a laparotomy; there was no bowel perforation and the issue related to a leak from Miss Dean�s feeding tube. A� gastroscopy showed that the PEG-J feeding tube was loose. The tube was� removed, and an alternative feeding tube was placed into the jejunum. The� operation itself was uneventful and relatively straightforward; Miss Dean was� expected to make a full recovery.� Miss Dean was at higher risk from any surgical procedure due to her co- morbidities. In the days that followed the laparotomy, Miss Dean developed a chest infection was prescribed antibiotics. The operation did make a� contribution to Miss Dean having developed the chest infection. Miss Dean�s� operation wound site then developed signs of dehiscing; she was taken back to theatre on 4 September 2023, due to complete separation of the wound� edges. The risk of complications was increased by virtue of this being the� second general anaesthetic within a short period of time.� Following Miss Dean�s return to the intensive care unit after the operation on 4 September 2023, she experienced a sudden deterioration and went into� cardiac arrest shortly after 17:00. There were extensive efforts at� resuscitation, but these were ceased shortly after 18:10.	I have sent a copy of my report to the Chief Coroner and the following: � [REDACTED] � Sophie Ann Dean�s mother and father � I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner.	Hospital Death (Clinical Procedures and medical management) related deaths	University College London Hospitals NHS Foundation Trust
04/03/2024	2024-0120	Lee Hughes	Inner West London	Chief Executive Oxleas NHS Trust via email� Chief Executive, NHS England � via email	Between 26th February 2024 and 29th February 2024, evidence was heard before a jury touching the death of Mr Lee Martin Hughes, also known as Martin Lee Hughes. He had died on the 25th December 2021, aged 50 years whilst remanded in HMP Wandsworth. � Medical Cause of Death � 1 a Methadone and Benzodiazepine intoxication � � � How, when, where and in what circumstances the deceased came by his death: � Lee Martin Hughes was remanded to HMP Wandsworth on 18th December 2021. He was found deceased in his cell in HMP Wandsworth on 25th December 2021 at approx. 0500. On arrival, the nurse gave him a COWS score of 12 and a CIWA score of 12-13. He was familiar to the nurse based on previous visits and she noted him looking healthier than previously. Mr Hughes reported drug use of [REDACTED] heroin /day; [REDACTED]�cocaine; diazepam tablets; cannabis. He also reported [REDACTED] alcohol/week. We consider this report to be unreliable based on other evidence we heard. His urine test was positive for: opiates (not specifically heroin}; cocaine; diazepam; cannabis. His urine was negative for methadone.He was prescribed�[REDACTED] diazepam twice daily, administered on 18th, 19th, and 20th; �and [REDACTED] methadone�on the 18th and the 19th and 20th�� Based on a COWS score of 2 found on 19th December 2021 we understand that: On 20th��December 2021, the Doctor increased his methadone prescription to [REDACTED] this medication was sufficient to control his signs of withdrawal. [REDACTED] to be titrated up over the following days. Our understanding is this was reasonable and appropriate based on a COWs score of 7 and BNF guidance. We believe this increase in methadone did contribute to his death, but does not equate to a failure in care. He was declined an increase in methadone on 23rd December 2021. Our understanding is this was appropriate. He showed signs of intoxication on 23rd December 2021 (nodding off). We believe based on the evidence in hindsight it would have been appropriate to omit a dose of methadone on 23rd December 2021, despite confounding factors. We found evidence of multiple events where Mr Hughes was unrousable on 24/12/2021, in order to administer diazepam. Based on the evidence, we do not believe this was appropriately managed by healthcare. We have seen insufficient evidence to believe he was seen awake or vaping on 24th December 2021 at 2100. Based on the evidence, we understand his consciousness to have been impaired when he was visited by the nurse at c. 2110 on 24th December 2021. Medical help should have been sought: Code Blue should have been called at 2110. Medical escalation to the HOTEL nurse when the medication could not be administered by the Pharm Tech at 18:10. Based on this evidence, we believe there a really serious (gross) failure to care for Mr Hughes, encompassing the behaviour of the nurse who entered the call at 21:10. Had care been sought, we believe Mr Hughes would have survived at this time. We believe this was a lost opportunity . We find the medical cause of death to be methadone and Benzodiazepine Intoxication. As a footnote, we believe Mr Hughes�s knowledge of the system (drug seeking behaviours) contributed to his death. We note the lack of communication between disciplines in HMP Wandsworth was a contributing factor to Mr Hughes�s death, specifically � Pharmacy techs not adequately escalating the reason that Mr Hughes could not be medicated, including the lack of real time and accessible written notes. The delay in trying to medicate Mr Hughes between the pharmacy techs alerting the day nurses for a second time at 18:10 and the night nurse first visiting Mr Hughes at 20:42. � Conclusion of the Jury as to the death: � Drug-related Misadventure contributed to by Neglect.	Extensive evidence was taken during the inquest from multiple live witnesses, written statements, and exhibited reports. Of relevance to this report in addition to the findings of the jury above, which I do not repeat: � The independent expert instructed by the court in this case in this case raised multiple concerns: �� That the GP who increased Mr Hughes�s methadone on 20th December 2021,�did this by applying guidelines without full consideration of evidence from others, for example his COWS score of 2 the previous day after �methadone, that Mr Huahes had slept that the nurse who knew him felt he was not experiencing a withdrawal. Further, the assessment that this GP made relied largely upon subjective symptoms rather than objective signs to form a COWS score of 7 and increase the methadone to a level that proved ultimately fatal with the concurrent administration of benzodiazepines, rather than leaving Mr Hughes at the same dose and reviewing him. That no dose of methadone was omitted on 23rd December 2023 despite Mr Hughes nodding off in the consultation. That Mr Hughes would have been highly likely to have survived even if emergency help was requested at the last interaction at 21:10, and naloxone and other supportive care had been given. That tolerance to opiates can fall away completely within 3 to 4 days of lack of opiate use, increasing risks of death if for example methadone is started. That due the long half life of methadone that it takes 5 days of same dose prescribing before the level in the blood stream stabilises. That most deaths from methadone occur in the first two weeks of starting the drug. Mr Hughes died on day 7. � There was at that time, no reliable drug testing for illicit drugs, especially SPICE, available for near patient testing. � That one reason for prescribing cited by the doctors was to mitigate the drive for the inmate to use illicit drugs, which have their own dangers. � Evidence was taken that illicit drugs are widely available in HMP Wandsworth, however the toxicology findings were consistent with him having died solely from methadone and diazepam as prescribed. � Other evidence was that the pharmacy technicians had no training in consciousness assessment and did not record their interactions on the medical records ( System One). � � Since Mr Hughes�s death an SI was undertaken and many lessons were learned and procedures changed within Wandsworth, including the following matters: � Pharmacy technicians have been trained as to how to assess consciousness and the risks of sedative drugs especially when given in combination. That emergency medical assistance should be sought when an inmate shows signs of impaired consciousness. That pharmacy technicians should record their patient/inmate interactions on System One. That this case has raised awareness across the prison estate of dangers of methadone, especially when prescribed alongside benzodiazepines or other sedatives, prescribed or illicit drugs. That all prescribing for those inmates that require pharmaceutical intervention for withdrawal is undertaken by the Substance Misuse Team. That the use of objective assessment to assess withdrawal signs is emphasised. That on commencing methadone consideration is given to the time spent in custody before remand in prison as to how much methadone should be prescribed in view of the risks of decreasing tolerance to cardiorespiratory effects that may have taken place whilst in custody when prescribing methadone. That especial consideration should be given when methadone is prescribed in combination with other sedative drugs. That policies reiterate that methadone should be withheld if patient/inmate is showing signs of intoxication. That there is better availability of near patient testing for illicit drugs, including SPICE. � Much of this is clearly good practice and there would be benefits if these changes and improvements in practice were adopted across the orison estate. To this end, this report has also been sent to NHS England, so that the lessons learned from this death may be applied to all prison health care services.	I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Sister of Mr Hughes : [REDACTED] � Governor, HMP Wandsworth, H_eathfield,Road, Wandsworth, London. Sw18 3HU. Investigator, PPO, Third Floor, 10, South Colonnade, Canary Wharf, London. E14 4PU. I am also under a duty to send the Chief Coroner a copy of your response. � The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Oxleas NHS Trust \| NHS England