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Inquests (PFDs)
Date | Reference | Deceased | Coroner Area | Sent to | Investigation | Circumstances | Sent to | Categories | Also sent to |
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22/02/2024 | 2024-0105 | Kim Stroud | Norfolk | Chief Executive Queen Elizabeth Hospital Gayton Road King�s Lynn Norfolk PE30 4ET | On 27 October 2022 I commenced an investigation into the death of Kim Georgina STROUD aged 65. The investigat ion concluded at the end of the inquest on 14 February 2024. �
The medical cause of death was:
la) Idiopathic Pulmonary Fibrosis
2)�Bladder Cancer, Covid Pneumonia �
The conclusion of the inquest was: � Natural causes. | Mrs Stroud was admitted to hospital on 4 August 2022 for a transurethral resection of bladder tumour which had been cancelled 5 times. She became unwell on 15 August 2022 with a chest infection against a background of severe interstitial lung disease and chronic type 1 respiratory failure . She tested positive for covid on 10 September 2022. Despite being on multiple antibiotics for chest infections and all other treatment she remained on high oxygen demand and was episodically confused. She died suddenly on 11 October 2022. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] (Daughter)
The Nursing and Midwifery Council
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I have also sent it to
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Department of Health Care Quality Commission HSIB
Healthwatch Norfolk
NHS England and NHS Improvement
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who may find it useful or of interest.
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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.
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I may also send a copy of your response to any person who I believe may find it useful or of interest.
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The Chief Coroner may publish either or both in a complete� or redacted or summary form.� He may send a copy of this report to any person who he believes may find it useful or of interest.
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You may make 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: Queen Elizabeth Hospital | |
20/03/2024 | 2024-0154 | Anne Rowland | Surrey | Chief Executive Surrey and Sussex Healthcare NHS Trust
Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH | INQUEST �
An inquest into Mrs Rowland�s death was opened on 20 April 2023. The inquest was resumed on 24 January 2024 and concluded on 20 March 2023. �
The medical cause of Mrs Rowland�s death was:
1a. Aspiration Pneumonia
1b. Dementia �
2.Neck of Femur Fracture (repaired 3 March 2023)
With respect to where, when and how Mrs Rowland came by her death a narrative conclusion was recorded on the Record of Inquest as follows:
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On 27 February 2023 Anne Johnston ROWLAND whilst a resident of a care home in Oxted, Surrey suffered a neck of femur fracture following a collision and fall with another resident who was partially sighted. Mrs Rowland was taken to East Surrey Hospital, Redhill on the same day and on 3 March 2023 she underwent fixation surgery. Her dementia and the immobility caused by waiting for her operation contributed to her developing aspiration pneumonia following surgery. Her condition deteriorated resulting in her death at East Surrey Hospital on 31 March 2023. There was no clinical reason for surgery not taking place until 3 March 2023. | During the course of the inquest the court heard that the NICE Guideline on the Management of Hip Fractures recommends that hip surgery take place on the day of the injury or the day thereafter and that this is because early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia.
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The court heard evidence that Mrs Rowland was clinically fit for surgery following her admission to East Surrey Hospital on 27 February 2023 but that her surgery did not take place because other trauma patients were prioritised ahead of her based upon their relative clinical need.
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The court heard that East Surrey Hospital has a dedicated list and operating theatre for trauma patients but that on some occasions demand outweighs capacity, meaning that patients are prioritised according to clinical need, meaning that is not possible to perform all operations with the timeframe set out in the NICE guidelines.
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The coroner also heard that theatre capacity has on occasions been compromised by infrastructure failings; the orthopaedic theatres require new air handling and chillers and the construction of a new building to provide a platform for the new plant. That work has yet to be completed.
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The coroner heard that the Trust is currently applying a metric of 48 hours to surgery from admission and not the NICE recommended guidance. | COPIES
I have sent a copy of this report to the following:
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Chief Coroner
Mrs Rowland�s family | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Surrey and Sussex Healthcare NHS Trust | |
29/09/2023 | 2023-0354 | Douglas Nickols | Surrey | Chief Executive Surrey and Sussex Healthcare NHS Trust Trust Headquarters East Surrey Hospital Canada Avenue Redhill RH1 5RH | INQUEST �
An inquest into Mr Nickols� death was opened on 18 April 2023. The inquest was resumed and concluded on 25 September 2023. �
The medical cause of Mr Nickols� death was: �
1a. Bronchopneumonia �
2. Fractured Left Neck of Femur (Operated 5 March 2023), Frailty of Old Age �
With respect to where, when and how Mr Nickols came by his death it was recorded at Box 3 of the Record of Inquest as follows:
Mr Nickols was an elderly man who suffered an unwitnessed fall at his care home on 28 February 2023, as a result of which he sustained a fractured left neck of femur. On the same day he was admitted to East Surrey Hospital and on 5 March 2023 he underwent fixation surgery. He subsequently deteriorated with Bronchopneumonia, resulting in his death at East Surrey Hospital on 11 March 2023.
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The inquest concluded with a short form conclusion of �Accident� together with the following short narrative conclusion:
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Following his admission to East Surrey Hospital on 28 February 2023 Mr Nickol�s surgery did not take place until 5 March 2023. Mr Nichols therefore remained immobile for a number of days prior to the operation taking place, which contributed to his death. There was no clinical reason for the surgery not taking place until 5 March 2023. | During the course of the inquest the court heard that the NICE Guideline on the Management of Hip Fractures recommends that hip surgery take place on the day of the injury or the day thereafter and that this is because early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia.
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The Court heard evidence that Mr Nickols was clinically fit for surgery following his admission to East Surrey Hospital on 28 February 2023 but that his surgery did not take place because other trauma patients were prioritised ahead of him based upon their relative clinical need.
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The Court heard that East Surrey Hospital has a dedicated list and operating theatre for trauma patients but that on some occasions demand outweighs capacity, meaning that patients have to be prioritised according to clinical need, meaning that is not possible to perform all operations with the timeframe set out in the NICE guidelines.
CORONER�S CONCERNS
The MATTER OF CONCERN is:
On some occasions at East Surrey Hospital it is not possible to perform operations on patients with fractured hips on the day of admission or the day thereafter, which is the timeframe set out in the NICE Guidelines on the Management of Hip Fractures. Early mobilisation is recommended for hip fracture patients to reduce the risk of complications, including pneumonia. The Coroner is concerned that in failing to comply with the NICE guidelines in this way, the Trust is placing such patients at risk of early death | ANNA CRAWFORD
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Anna Crawford
H.M Assistant Coroner for Surrey Dated this 29th day of September 2023 | Care Home Health related deaths
This report is being sent to: Surrey and Sussex Healthcare NHS Trust | |
08/11/2023 | 2023-0434 | Owen Garnett | Warwickshire | Chief Executive and Chair of Unity MAT (Concerns 1 and 2 only)
Health and Safety Executive (concern 3 only) | INVESTIGATIONS and INQUESTS
Owen Paul Garnet died on 11 January 2023 at Warwick Hospital, Warwickshire. I had jurisdiction to hear an inquest into his death, which concluded on 27 October 2023. My conclusion was misadventure. | Owen was a 19-year-old student at the Welcome Hills school. Owen was regarded as having a severe learning difficulty.
Owen had numerous health problems including a difficulty in swallowing. He also suffered from Pica (an eating disorder characterised by a tendency to eat non-edible substances).
Because of this tendency, Owen needed to be constantly watched to ensure that he did not eat such items. This was recognised in the school�s risk assessments which initially recorded that Owen should �Never be left alone when out� and to which was later added in bold �NB due to Pica, a named person must watch Owen at all times, to ensure he doesn�t eat anything particularly leaves and twigs.
However, his carer noted that Owen was consuming items whilst at school such as twigs and other non-edible items. She raised this issue with the school on many occasions over a number of years. She was monitoring his stools and had photographs of such items in his stools. She sent the photographs to the social worker and believed they had been forwarded to the school. The school say they did not receive the photographs, but they were certainly aware of her concerns. In November 2022, Owen�s carer specifically raised concerns surrounding blue paper towels at a meeting attended by Owen�s class teacher.
On 4 January 2023 Owen was discovered to have blue paper towel in his mouth and a message was sent to his carers saying this had occurred. A near miss report made but no action was taken as a result of the report.
On 9 January 2023, contrary to the requirements of his risk assessment, Owen was outside of the classroom and was unsupervised.
When Owen was located, it was discovered that he had crammed a significant amount of blue paper towel into his mouth and throat and was choking.
Resuscitation attempts were made, and Owen was transported to Warwick Hospital. Owen had suffered a hypoxic brain injury. A decision was taken to remove life support and he died on 11 January 2023. | I have sent a copy of my report to the Chief Coroner, Owen Garnet�s family, the Chef Executive and the Chair of Unity MAT and the Health and Safety Executive.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Unity MAT | Health and Safety Executive | |
30/04/2024 | 2024-0232 | Mohamed Ellaboudy | Berkshire | Chief Executive of Berkshire Healthcare NHS Foundation Trust | INVESTIGATION �
I conducted an inquest into the death of Mohamed Ahmed Hany Ellaboudy (known to the family as Moh), which concluded on 24th of April 2024. I recorded a narrative conclusion as follows: Mohamed Ellaboudy died after placing himself in front of a moving train. His actions were deliberate, but his mental state and capacity to form intention are unclear.
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The family requested me to refer to the deceased Moh. I will reflect that in this report. | Moh was a 34 year old man who had been diagnosed with paranoid schizophrenia. He had a significant mental health history, having been admitted to psychiatric hospitals in 2011, 2017 and 2020, before his final admission in 2022. He had also been an inpatient in psychiatric units abroad. There had been previous attempts by Moh to take his own life. �
Previous relapses in his mental health state had been associated with Moh declining to take his anti-psychotic medication. He was receiving Aripiprazole via depot injection. �
Moh stopped taking this medication again in December 2021, and he was detained under the Mental Health Act in July 2022, under Section 2 of the Mental Health Act 1983. � Moh was discharged from Prospect Park Hospital, Reading Berkshire in August 2022. A discharge summary was sent to his GP practice at that time, but there was no further correspondence from the mental health trust to the GP until the end of March 2023. �
The inquest focused on the time from when Moh first stopped taking his anti-psychotic medication again (March 2023), to the time of his death (8th September 2023). During that time period, there were two telephone calls to his GP, and a telephone call with the practice mental health nurse.
Looking at the same period of time from the mental health team�s perspective, there were two appointments with a specialist doctor (both by telephone), and two brief telephone conversations with community mental health team nurses.
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By March 2023, the mental health teams knew that Moh was no longer complying with his medication. They knew his previous history of relapses when coming off medication. They knew that Moh was not working. These had been clearly described in a previous discharge summary as relapse signs for Moh. There was no face to face appointment to assess other potentially important risk factors, such as self neglect.
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We heard evidence that Moh himself insisted on not having face to face appointments as he feared being detained under the Mental Health Act again. I accepted evidence from the psychiatry witness that it is sometimes better to have at least some contact with a patient, rather than pressurising them and the patient refusing to have any contact at all. Whilst this may be true in practical terms, there was no documented rationale in this sense. It was accepted by the trust that there was a distinct lack of proactivity, rather than a conscious plan, particularly in the last months of Moh�s life.
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There were matters which troubled me about Moh�s case. He was unwell enough to be detained under the Mental Health Act in July 2022. By then he had had multiple previous relapses and admissions and attempts to end his own life. After being discharged from Prospect Park Hospital, he was under the auspices of a care co-ordinator, who largely spoke to him by telephone. It is very stark to note that the last face to face contact he had with any mental health professional (after being discharged from Prospect Park Hospital in August 2022) was February 2023, when he went for his last depot injection. He had no face to face appointment after that, and he died 7 months later.
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I was also concerned to note that the last multi-disciplinary team discussion about Moh was in May 2023. A later MDT would have been an opportunity for Moh�s case to be considered in terms of alternative contact methods and more comprehensive assessment of risk. The evidence showed that Moh had expressed a clear wish not to have face to face appointments for fear of being detained under the Mental Health Act again. A number of other relapse signs were also present and likely to be escalating in the final months of his life. | I have sent a copy of my report to the Chief Coroner and to Moh�s family.
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I have also sent this report to the following recipients, who have an interest in this matter:
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Legal representative for Moh�s GP.
Legal representative for Berkshire Healthcare NHS Foundation Trust.
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who may find it useful or of interest.
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I am also under a duty to send the Chief Coroner a copy of your response.
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The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
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You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Railway related deaths | Mental Health related deaths
This report is being sent to: Berkshire Healthcare NHS Foundation Trust | |
14/02/2024 | 2024-0081 | Teresa Bennett | North West Wales | Chief Executive of Betsi Cadwaladr University Health Board, [REDACTED] | On the 8th December 2021, I commenced an investigation into the death of Ms Teresa Ann Bennett. The investigation concluded at the end of the inquest on the 9th February 2024. | Teresa Ann Bennett was a female, aged 57 at the time of her death. She had a number of significant comorbidities, and her case was unusual and complex. Mrs Bennett was prescribed and taking 13 separate medications at the time of her death, seven of which, including Fentanyl, had side effects linked to the central nervous system. �
On the evening of the 30th November 2021, Ms Bennett�s son had seen her taking her medication as usual. Ms Bennett retired to bed around 30 minutes or so later. Around 3am on the 1st December 2021, Ms Bennett�s son found her asleep on the bedroom floor, appearing to have fallen from the bed. He helped her back to bed, ensuring she was comfortable, and left the room. At around 12pm on the 1st December 2021, Ms Bennett�s son noticed that she was still in bed and it became apparent that she had passed away. Ms Bennett�s son called the Emergency Services who attended and declared life extinct at 13.12pm. � A post mortem examination was ordered and the cause of death recorded at inquest was: 1a Multi organ failure 1b Fatty liver and combined drug toxicity � Mrs Bennett was prescribed [REDACTED] micrograms of Fentanyl over 72 hours. This was provided as one [REDACTED] patch and one [REDACTED] patch, both to be used at same time and identifiable as being different in size. At post mortem, [REDACTED] Matrifen (a form of fentanyl) patches were found on Ms Bennett�s legs, two on the left and one on the right. This would amount to a dose of [REDACTED]. This dose differs from what was prescribed and issued by the GP and correlates to a significant dose increase of [REDACTED] over 72 hours, which is the [REDACTED] equivalent of
of morphine daily. The toxicological analysis showed multiple drugs with Fentanyl being within the toxic and fatal range.
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It was recognised that Ms Bennett was prescribed a high dose of Fentanyl. Ms Bennett had been on a dose of [REDACTED]/ hr over 72 hours since 2008. The instructions recorded in the GP notes simply stated �remove old patch and apply new patch every 72 hours� There was no evidence to suggest that Ms Bennett was not compliant with her medications. There was no evidence of ordering discrepancies, no stockpiling or using the medication incorrectly and there was nothing to indicate that Ms Bennett raised any concerns or mentioned any difficulties with the medication she was taking.
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The prescription dose of Fentanyl had not changed since 2008 and the directions for use had not changed. There was no evidence that the application of Fentanyl patches resulting in a dose of [REDACTED] micrograms was intentional. I found that Ms Bennett had inadvertently overdosed on Fentanyl, and that, in combination with other medicines, a number of which possessed the ability to depress the nervous system, led to her death.
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Ms Benett�s GP practice was managed directly by the Health Board. It is Standard Health Board practice for medication reviews to be completed at 12-15 month intervals but, in Ms Bennett�s case, that target had not been met on a single occasion since 2015. There is a lack of monitoring and no standardised process for medication reviews in the Health Board managed practices.
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There is a risk of harm if medication reviews are not undertaken at regular intervals, including a risk of death in complex cases, like Ms Bennett�s. There is also a risk of harm or death if all pertinent matters are not considered during the reviews. At inquest, the Health Board produced an improvement plan that, inter alia, included actions to address the lack of compliance with the 12-15 monthly medication reviews. The target completion date for addressing the lack of compliance with the 12-15 monthly medication reviews is the 31st May 2025, a further 15 months from now. This, in my view, is not quick enough and I am concerned that future deaths may occur. | I have sent a copy of my report to the Chief Coroner and to Ms Bennett�s son, as an Interested Person
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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.
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The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
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You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Alcohol, drug and medication related deaths | Wales prevention of future deaths reports (2019 onwards)
This report is being sent to: Betsi Cadwaladr University Health Board | |
09/02/2024 | 2024-0071 | Narjit Gill | Coventry and Warwickshire | Chief Executive of Coventry and Warwickshire NHS Partnership Trust
Department of Health
[REDACTED], sister of the deceased
Chief Constable of Warwickshire Police | On 12 May 2023 I commenced an investigation into the death of Narjit Gill, aged 61 years. The investigation concluded at the end of the inquest on 9 February 2024. The conclusion of the inquest was suicide, with the medical cause of death confirmed as hanging. | 1. Mr Narjit Gill died on 5 May 2023, by hanging himself [REDACTED]
2. He had recently been in contact with mental health services, following reports to police from his friend, that he had attempted suicide. Mr Gill received a number of telephone calls, home visits and face to face appointments, commencing 24 April 2023 until his death.
3. Mr Gill was seen at his home by registered mental health practitioners, on 3 May 2023. During this visit, he disclosed that he continued to experience suicidal thoughts �on an almost constant basis�, and he reported that he had attempted to ligate himself from a tree in the garden on a number of occasions and had also made an attempt to ligate from a stair rail within his home.
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4. [REDACTED]
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5. Mr Gill continued to express suicidal ideation, although he agreed to engage with Mental Health services, to attend all appointments and to take anti-depressant medication.
6. A home visit by the same mental health practitioners, was arranged for Mr Gill on 5 May 2023. Sadly, upon their arrival, Mr Gill was found to have ended his life by hanging himself [REDACTED]. | I have sent a copy of my report to the Chief Coroner and to the following Interested Person, [REDACTED], sister of the deceased. I have also sent it to the Chief Constable of Warwickshire Police, who may find it useful or of interest.
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I am also under a duty to send the Chief Coroner a copy of your response.
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The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Coventry and Warwickshire NHS Partnership Trust | Department of Health and Social Care | Warwickshire Police | |
02/02/2023
| 2023-0040 | Daniel Futers | Sunderland
| Chief Executive of Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust | On 8th April 2022 I commenced an Investigation into the death of Daniel Graeme Futers, who was born on 13th June 1990 and who died at the Wearmouth Bridge in Sunderland on 5th April 2022 aged 31 years.
The Investigation concluded at the end of a 3-day Inquest on 1st February 2023. �
The conclusion of the Inquest was: �Daniel Graeme Futers took his own life, in part because the complexity of his condition was not fully appreciated, and appropriate precautions were not in place to prevent him from doing so.�
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The medical cause of death was:
Ia Multiple Injuries
Ib Fall From a Height
II Schizoaffective disorder | Daniel Graeme Futers died on 5th April 2022 at the Wearmouth Bridge, Sunderland [REDACTED], and fell to his death. There had been a number of failings in his Mental Health Care and treatment and in particular the management of his leave from Hopewood Park and his prospective discharge from state detention. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: �
��Family and their Solicitors and Counsel
��Care Quality Commission (CQC)
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015)
| Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust |
12/05/2023 | 2023-0150 | Odessa Carey | North Northumberland and South Northumberland | Chief Executive of Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust | On 10 April 2019 HM Senior Coroner Tony Brown commenced an Investigation into the death of Odessa Carey who was born on 20 May 1945 and who died within [REDACTED] on 8 April 2019. He adjourned and suspended the investigation under Schedule 1 of the CJA as he was informed on 15 April 2019 that an individual had been charged with a homicide offence of murder.
On 11 March 2020 the perpetrator was found to have committed Murder and sentenced under Section 38 Hospital Order with a Section 41 Restriction.
I made the decision to resume the Inquest, as there was sufficient reason to do so as the perpetrator had been involved with mental health services for an extensive period of time and was still open to services at the time of Odessa Carey�s death. The conclusion of the inquest was �Unlawfully killed�.
The medical cause of death was 1 a Blunt force head injury. | Odessa Carey was last seen alive on the evening of Thursday 4th April 2019 within her home address [REDACTED], Ashington. She was attacked by the perpetrator. On 7th April 2019 the police have attended [REDACTED], Ashington and found the body of the deceased covered with bedding sheets. The body was without the head. Police officers have then attended another address and following a systematic search of that property, the perpetrator was found and arrested in connection with the murder of the deceased.
On 11 March 2020 the perpetrator was found to have committed Murder and sentenced under Section 38 Hospital Order with a Section 41 Restriction.
I resumed the Inquest as there was sufficient reason to do so as the perpetrator had been involved with mental health services for an extensive period of time and was still open to services at the time of Odessa Carey�s death. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of Odessa Carey 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. | Other related deaths
This report is being sent to: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust | |
17/12/2024 | 2024-0692 | Mary Whitlock | Essex | Chief Executive of Mid & South Essex NHS Trust | On 1 September 2023 I commenced an investigation into the death of MARY MARGARET WHITLOCK, AGE 84. The investigation concluded at the end of the inquest on 17 December 2024. The conclusion of the inquest was Ia Aspiration of food contents Ib Fracture of Cervical Vertebra and Dementia
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Accident contributed to by neglect | Mary Whitlock died at Broomfield Hospital on 23 August 2023. Mrs Whitlock sustained� a fracture of her cervical vertebra when she tripped at her care home and struck her head against the wall on 21 August 2023. Mrs Whitlock was conveyed to hospital with neck pain. CT scan of her head revealed no bleed or infarct and Mrs Whitlock returned home that night; no imaging was completed of the neck. Mrs Whitlock was in pain and could not swallow paracetamol the next morning and was readmitted to Broomfield Hospital where further scans revealed cervical fractures at C1 and C2. Advice was that she was not suitable for surgical intervention and was for conservative treatment with a collar that was difficult to tolerate. Broomfield Hospital did not provide the collar clinically recommended until 23 August 2023. Swallowing problems were a known risk for Mrs Whitlock�s injury and there was no plan for managing oral intake. Concerns about swallowing tablets and oral administration of analgesia were noted in the medical records overnight and not handed over to the day shift or reviewed in the ward round. Mrs Whitlock suffered aspiration following assisted feeding of her lunch on 23 August that was treated with suctioning and oxygen with improvement in her condition. Mrs Whitlock was required to be nil by mouth, undergo chest x-ray, a Speech and Language Team assessment, antibiotics and intravenous fluids. This information was not shared with all the ward staff due to staff shortages. Mrs Whitlock was fed some of her remaining lunch and suffered shortness of breath and oxygen desaturation that required a emergency medical call at approximately 13:00 hours and Mary was place on end-of-life care and died. Mrs Whitlock sustained a Fractured Cervical Vertebrae with Dementia that put her at risk of aspiration. and she was fed when experiencing swallowing difficulties. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
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Family
Essex County Council
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I have also sent it to Care Quality Commission who may find it useful or of interest.
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The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 & South Essex NHS Trust |
18/04/2023 | 2023-0121 | David Levett | Northamptonshire | Chief Executive of National Highways | On 18th April 2018, I commenced an investigation into the death of David Levett aged 53 years. The investigation concluded at the end of the Inquest on 13th April 2023.
The conclusion of the Inquest was:
1a Bronchopneumonia
1b Head and chest injuries sustained in a road traffic incident 28.1.18
2 Megacolon due to faecal loading. | On the evening of 28th January 2018, a car broke down on a stretch of the M1 south-bound motorway near Daventry known as a �Smart Motorway�. A second vehicle came to the rescue of the first and parked behind the first vehicle in lane 1. A lorry collided with the rear of the second vehicle, pushing it into the rear of the first vehicle. Mr David Levett was a rear seat passenger in the second vehicle. He received severe head and chest injuries and was conveyed to Hospital. He succumbed to his injuries and was confirmed deceased on 24th February 2018. �
My conclusion was Road Traffic Collision. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
The family of David Levett
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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.
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I may also send a copy of your response to any person who I believe may find it useful or of interest.
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The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
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You may make 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: National Highways | |
19/03/2024 | 2024-0151 | Ian Dixon | Manchester South | Chief Executive of Stockport Metropolitan Borough Council
Chief Executive of Stockport Homes | On 5th July 2023 an investigation was commenced into the death of Ian Dixon, then aged 72 years. The investigation concluded at the end of the inquest on 13th December 2023. At the end of the Inquest, I recorded a narrative conclusion that Mr Dixon died as a result of traumatic brain injury following a fall �on a background of chronic alcohol excess with cerebellar atrophy.
The medical cause of death being:
1a) Traumatic Head Injury
1b) Chronic Alcohol Excess with Cerebellar Atrophy | Ian Dixon was a recovering alcoholic and had a history of falls. He had been suffering from confusion, was unsteady on his feet and was awaiting a memory assessment. � Following an assessment by an Adult Social Care duty worker on 31st May 2023, a decision was made to expedite the installation of an additional handrail on his staircase to try to minimise the risk of falls. Prior to that meeting Mr Dixon had hurt his left arm and hand, and the additional rail would mean that he could hold it with his undamaged hand to stabilise himself on the stairs. The installation was to be completed through Stockport Homes and the expectation was that this would be completed within 3 days in accordance with the timeframe for an urgent request. �
On 8th June 2023, Mr Dixon was found deceased following a fall at the bottom of the stairs in his home. The fall caused an extensive skull fracture with an acute right sided subdural hematoma. �
A post-mortem examination showed chronic cerebellar atrophy, due to chronic alcohol excess which likely caused his confusion and ataxia, leading to falls. A police investigation confirmed that there was no evidence of suspicious circumstances or third-party involvement. �
At the time of his death no handrail had been installed. The inquest heard that there is no process in place for the council to be notified when requested work is completed or if there are any delays in work completion. The Inquest also heard that the work had been marked as complete on the Stockport Homes system even though the handrail had not been fitted. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:��[REDACTED], on behalf of the Family.
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I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Stockport Metropolitan Borough Council | Stockport Homes | |
20/01/2025 | 2025-0034 | Harry Southern | West Sussex, Brighton & Hove | Chief Executive of Sussex Partnership Foundation Trust | On 17 October 2023 I commenced an investigation into the death of Harry Benjamin SOUTHERN aged 19. The investigation concluded at the end of the inquest on 01 November 2024.��
The conclusion of the inquest was that: Harry Southern died on the 12th of October 2023 at Royal Sussex� County Hospital in Brighton. He tied a ligature around his neck the day before which led to hypoxic brain injury. He did so with the intention of ending his life. | Harry Southern had a history of mental illness and involvement from his GP, the Trust�s� mental health services and sessions with a private therapist. He had had a traumatic last�year of his life which involved the death of relatives, the breakdown of a relationship and the suicide of someone he knew. He had had a previous suicide attempt in June 2023 and in� October he left a final note and sadly took his life. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Sussex Partnership Foundation Trust�
[REDACTED], GP at Carden Surgery in Brighton
[REDACTED]�
[REDACTED]�
[REDACTED]�
[REDACTED]�(all family members)
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. I will send a copy to the Secretary of State for Health.�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of� interest. ��
You may make 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 | Suicide (from 2015) | Sussex Partnership Foundation Trust |
31/05/2024 | 2024-0293 | Glennis Connelly | Staffordshire and Stoke on Trent | Chief Executive of University Hospitals of Derby & Burton NHS Foundations Trust
Minister of Health | On 14 June 2023 I commenced an investigation into the death of Glennis CONNELLY aged 87. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was that of a narrative conclusion of drug related (prescription medication) contributed to by neglect. | Glennis CONNELLY died on 11th November 2022 at her home address [REDACTED] Swadlincote Derbyshire . She died from the effects of end stage renal failure, due to tubulo interstitial nephritis which was caused by the prescription of tazocin, which she was prescribed on 14th Sept 2022. She had previously been prescribed tazocin, to treat her respiratory infections in October 2019 and January 2020 and was found to have an allergy to the drug which has caused tubulo interstitial nephritis. On each occasion she suffered an acute kidney injury which was successfully treated with steroids. Despite both instances being at the Queens Hospital Burton Upon Trent, the information relating to her allergy to tazocin was not recorded� in hospital records held at Queens Hospital Burton Upon Trent, although it was available , and accessible through her Summary Care Records held by her General Practitioner and clinic letters, which were not accessed. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
1 Queens Hospital Burton
2 Family
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Alcohol, drug and medication related deaths
This report is being sent to: University Hospitals of Derby and Burton NHS Foundation Trust | Department of Health and Social Care | |
21/06/2024 | 2024-0345 | Kevin Cashin | Manchester North | Chief Executive of the College of Policing | On 25 July 2022 an investigation into the death of Kevin Michael Cashin was commenced. The investigation concluded at the end of the inquest on 20 June 2024. The jury found that the medical cause of death was
1a) hypoxic brain injury and haemothorax
1b) post cardiac arrest syndrome
1c) out of hospital cardiac arrest due to restraint in association with drug induced psychosis and metabolic acidosis. The jury returned a narrative conclusion. | CIRCUMSTANCES OF DEATH �
In the early hours of 20 July 2022, officers from Greater Manchester Police received a call from Kevin Cashin asking that police attend his home address as he had concerns that people were coming to his home with guns. Kevin was experiencing an extreme episode of Acute Behavioural Disturbance due to having ingested a significant amount of cocaine. When the police officers arrived, Kevin had barricaded himself into his bedroom. The officers made efforts to engage with Kevin and to reassure him that they were there to help him. � Without warning, Kevin opened a first floor bedroom window and dropped onto an area of loose slate at the front of the house. Kevin was immediately restrained by officers and once handcuffs were secured, he was sat up and supported in a seated position so that his airways were kept open. Kevin began to deteriorate and stopped breathing. He was resuscitated and transferred to Salford Royal Hospital where Kevin was diagnosed with an unsurvivable hypoxic brain injury. He died later that morning. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:-
The family of the Deceased
Chief Constable of Greater Manchester Police
North West Ambulance Service
Independent Office of Police Conduct
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary from. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me the coroner at the time of your response, about the release or the publication of your response by the Chief Coroner. | Other related deaths
This report is being sent to: College of Policing | |
24/10/2024 | 2024-0686 | Alice Clark | North West Kent | Chief Executive of the South East Coast Ambulance Service | On 19 January 2022 I commenced an investigation into the death of Alice Olivia CLARK. The� investigation concluded at the end of the inquest . The conclusion of the inquest was�
Narrative: The death of Alice Olivia Clark was due to a road traffic accident but that there was� a failure by the South East Coast Ambulance Service in their investigation of complaints they�had received from other members of their staff over the driving of�[REDACTED] where if it�had been acted upon could have changed the outcome.�
1a Lower Limb & Pelvic Fractures with Retroperitoneal Haemorrhage
1b Vehicular Crash
1c
1d
II | At 20.16 hours on Wednesday 5th January 2022, a road traffic collision involving a SECAMB�
ambulance was reported to Kent Police on the A21, Coastbound at Tonbridge. From the�
information known at the time of writing, it would appear that a marked SECAMB ambulance�
(Vehicle 1) was being driven by [REDACTED] to an emergency call on blue lights, when�
for reasons currently unknown, the vehicle has taken the slip road towards the layby (where�
the collision occurred) instead of the next exit, which goes off the A21 towards the Morley�s�
Road roundabout / A225. ��
Upon entering the layby, the ambulance has collided with the offside kerb, then rear nearside�
of a stationary and attended Scania Dropside lorry which was parked to the offside of the�
layby, the force of which has caused the ambulance to cross the layby to the nearside, where�
it has then collided with the rear of a stationary and attended Volvo Tanker cement lorry. ��
The impact caused the ambulance to become embedded into the rear of the tanker, trapping�
both the driver and front seat passenger (Miss Alice CLARK) within the vehicle. A third�
occupant,�[REDACTED] was seated in the rear of the ambulance. [REDACTED] was able�
to exit the ambulance with assistance however suffered severe concussion and possible bleed�
on her skull. ��
Miss CLARK was extricated from the front of the ambulance by KFRS and HEMS attended.�
Following assessment, HEMS Doctor�[REDACTED] stated there were no signs of life and declared life extinct at 21:42 hours. The driver [REDACTED] was also extricated from the front of the ambulance and flown to Kings College Hospital with life threatening injuries. Officers from the Serious Collision Investigation Unit were deployed to the scene and arrived to commence an investigation at 21:35 hours. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons Mr and Mrs Clark (parents of Alice Clark).�
I am also under a duty to send the Chief Coroner a copy of your response.�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He� may send a copy of this report to any person who he believes may find it useful or of interest.� You may make 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) | South East Coast Ambulance Service |
07/06/2023 | 2023-0181 | David Wood | Milton Keynes | Chief Executive � John Radcliffe Hospital �
MK Together Partnership | On 29 June 2022 I commenced an investigation into the death of David WOOD aged 56. The investigation concluded at the end of the inquest on 06 December 2022. The conclusion of the inquest was that: �
The deceased having recently undergone open heart surgery in Oxford developed a severe depression. He was found on 22nd June 2022 hanging at his home [REDACTED] Milton Keynes. | Mr. Wood had been suffering from depression and difficulty sleeping following his release from hospital after the surgery. He had been to see his doctor about this. On Wednesday the 22nd of June 2022 Mr. Wood was at home with his wife. During the afternoon Mrs. Wood went out leaving him sat in a downstairs chair. On her return he was no longer in the chair and she thought that he had gone upstairs to try and sleep. Later that evening at 8pm she went to wake him up. Mrs Wood found him suspended by the neck. | 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. | Suicide (from 2015) | Mental Health related deaths
This report is being sent to: John Radcliffe Hospital and MK together Partnership | |
08/02/2024 | 2024-0068 | Jake Baker | Surrey | Chief Executive � Surrey County Council,
Chief Executive � Care and Quality Commission | INQUEST �
An inquest into the death of Jake Baker was opened on the 13th August 2020 and resumed on the 23rd January 2021. The resumed inquest was adjourned on 2 occasions for further evidence to be provided and suspended to await the result of a prosecution under regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. � The inquest was concluded on the 14th December 2023. Evidence in respect of matters pertaining to this report was heard on the 1st February 2024. �
Jake Baker died on the 31st December 2019 at home at Queen Elizabeth Way, Woking and the medical cause of his death was: 1a Diabetic Ketoacidosis �
The narrative conclusion found that:
Jake Baker had twin diagnoses of learning disability and type 1 diabetes. He was not capable of, and had not been trained to, manage diabetes independently if he developed hyperglycemia and became unwell. His family had not been given any training to recognise a deterioration in Jake�s condition and when to seek emergency medical assistance.
�
Those involved in making decisions for Jake from the Surrey Care Leavers team and Childrens Services failed to ensure Jake�s safety when he went home for overnight contact from March 2019 by :
a.) Failing to obtain information about the risks posed by type 1 diabetes from specialist diabetic services.
b.) Failing to obtain information about Jake�s cognitive ability and how it impacted on his ability to manage his diabetes independently.
c.) Failing to undertake a risk assessment in relation to his ability to manage diabetes independently.
d.) Failing to create an adequate pathway plan which included a proper evaluation of what support Jake needed to have contact with his family e.) Failing to co-ordinate the agencies providing support for Jake to inform the pathway plan.
f.) Failing properly to plan for Jake�s care leaving by failing to hold properly minuted and informed meetings prior to making a decision that Jake could have unsupported contact with his family.
g.) Failing to ensure that Ruskin Mill Trust were aware that the local authority had not risk assessed Jake having unsupported contact with his family.
h.) Failing to inform Jake of the risks of going home unsupported and to suggest ways to mitigate the risks
i.) Failing to correctly identify that, had Jake been made aware of the risks and despite that insisted on going home unsupported without any mitigation in place, a capacity assessment would be required. Had such a capacity assessment been undertaken he would have lacked capacity to make that decision and safeguarding measures would have had to be taken.
�
There was a systemic failing on the part of Surrey County Council adequately to train and oversee personal advisers in relation to their legal obligations in preparing pathway plans.
�
Ruskin Mill Trust failed to ensure Jake�s safety when he went home for contact by:
a.) Failing to ensure that any employees involved with pathway planning meetings for Jake were fully informed about the extent of the risks posed by type 1 diabetes.
b.) Failing to risk assess the risk posed to Jake by his diabetic condition when he went home for contact.
c.) Failing to put in place a care plan informed by his diabetic specialist team, Jake, his family and staff.
d.) Failing to ensure that they were aware on a daily basis when he was away from the college what his blood sugar readings were. Had they done so they could have ensured admission to hospital at the latest by the morning of December 29th 2019.
e.) Failing to establish the nature of his condition when notified that he was unwell on the 30th December 2019 and to give appropriate advice that he needed immediate hospital admission.
�
The death was contributed to by neglect. | Jake Baker was made subject to a care order in 2009 and remained in the care of Surrey County Council until he turned 18 on the 29th March 2019. He was diagnosed with type 1 diabetes in 2014. He was diagnosed as learning disabled and in 2015 was assessed to have an overall IQ of 42 with working memory and processing scale of 50 placing him below the
0.1 centile in these domains.
�
Once subject to a care order he retained contact with his family in Woking during thrice yearly supervised contact visits. Following being diagnosed with type 1 diabetes he was cared for both at school and in his residential care home by staff who were given training by St Peter�s Hospital in relation to diabetes management. In September 2018 he was placed in a full-time residential placement at Ruskin Mill College. Whilst at the college the management of his diabetic condition was overseen by members of staff who supervised Jake whilst he took blood readings and calculated the insulin dose required. Secondary diabetic care transferred to Gloucester Royal Hospital.
�
Jake continued to have a social worker until he reached 18 years old when he became a care leaver and came under the auspices of the Surrey Care Leavers team. He was entitled to a personal adviser once he left care.
There was a statutory duty on the personal adviser to write a pathway plan for Jake which would include consideration of what support he required to sustain appropriate family relationships and how his health needs were to be met. The personal adviser was required to coordinate support and ensure that agencies providing services that contributed to the pathway plan were engaged in information sharing and pathway planning. No advice was sought from specialist diabetes services to inform the pathway plan and no risk assessment was undertaken in relation to the risks of Jake having unsupported contact with his family in so far as management of diabetes was concerned.
�
A referral was made to the Surrey County Council Transitions Team for an assessment of Jake�s care needs. The entry requirement for that team required an evidenced diagnosis of learning disability. The report containing the original diagnosis had been lost. Childrens Services were unable to obtain an up to date diagnosis of learning disabilities. Jake was assessed not to meet the threshold for the transitions team. He did not have the support of an adult social work team. This outcome was being challenged when he died.
�
Two professional meetings took place, attended only by local authority employees, prior to Jake�s 18th birthday and agreed that Jake should have unsupported staying contact with his family on the 29th March 2019. The meetings were unminuted and the emails which refer to the decisions made at the meetings make no reference to any consideration of the dangers inherent in Jake�s diabetic condition nor his ability to manage it unsupported. The local authority employees held the mistaken belief that if Jake wanted to go home unsupervised once he turned 18 there was nothing they could do to stop him.
�
Jake lacked the ability to be wholly independent in managing his diabetes. He was not given any information about the dangers inherent in him having unsupported contact if his blood sugars became deranged and he became acidotic. No capacity assessment was undertaken in relation to Jake�s ability to make a decision to go home unsupported.
�
His final looked after child and pathway planning meeting took place on the 27th March 2019 at Ruskin Mill College attended by his social worker, independent reviewing officer and 2 members of staff from the college.
There are no minutes of the meeting. The pathway plan was deficient in that the domain relating to contact with family was not filled in. The only reference to what would take place in relation to contact was that he would be supported with travel warrants by the local authority and would stay in touch with college staff so they know he was safe and when he was returning.
�
Jake had two overnights stays with his family in March and November 2019 of one and two nights respectively. He then asked his personal adviser for travel warrants to travel for contact from the 24th December to the 30th December 2019. No risk assessment was undertaken in relation to him having unsupported contact for this length of time by either his personal adviser or the college. In November 2019 he transferred to Glasshouse College in Stourbridge which was an internal transfer within the Ruskin Mill Trust Group.
�
On the 24th December 2019 Jake was dropped at his family home at Queen Elizabeth Way, Woking. He was provided with sufficient insulin for the stay. The family were not given any advice at any stage on how to keep Jake safe if he became unwell nor any emergency contact numbers. They were not given any training in diabetes management nor the symptoms which might suggest he needed immediate medical attention. Overnight from the 28th to the 29th December 2019 he developed diabetic ketoacidosis as a result of being hyperglycaemic in the preceding days. He began to vomit. He required immediate hospitalisation. On the 30th December 2019 the college was notified by his family that he was too ill to travel. The staff who were travelling to collect him were told to return to the college. His family was not told to take him to hospital. He was last seen alive at 11pm and found dead at 3am on the 31st December 2019. If Jake had been admitted to hospital at any time prior to 5 pm on the 30th December 2019 he would have been successfully treated.
�
The death was avoidable. | COPIES
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
Ruskin Mill Trust Gloucester Royal Hospital
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. | Other related deaths
This report is being sent to: Surrey County Council | Care Quality Commission | |
11/01/2023
| 2023-0012 | Lucy Jones | Gwent
| Chief Executive, Aneurin Bevan University Health Board | INVESTIGATION AND INQUEST �
On 29/03/2022 an investigation was opened into the death of Lucy Amanda Jones The investigation concluded at the end of the inquest on: 20/12/2022
The conclusion of the inquest was recorded as: Suicide
The medical cause of death was:
1a Asphyxia
1b Hanging
1c) Mental Illness | In 2019 Lucy Amanda Jones developed a serious mental illness which caused her to become stricken with paranoia. Despite receiving treatment and support, the problems she faced became overwhelming and on 12/03/22, Lucy took her own life by hanging�[REDACTED] in Abergavenny. | COPIES AND PUBLICATION
I have sent a copy of my report to the Chief Coroner and the following Interested Person (s)
The family of Lucy Amanda Jones 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. | Suicide (from 2015) | Wales prevention of future deaths reports (2019 onwards)
| Aneurin Bevan University Health Board |
30/05/2023 | 2023-0175 | Carol Clements | Birmingham and Solihull | Chief Executive, Birmingham Community Healthcare NHS Foundation Trust | On 8 November 2022, I commenced an investigation into the death of Carol Ann CLEMENTS. The investigation concluded at the end of the inquest.
The conclusion of the inquest was:�Died as the result of an accident | The deceased was a resident at Perry Trees Centre following discharge from hospital after surgery to repair a hip fracture. Whilst at the centre, she was incorrectly assessed as being a medium risk of falls, when in fact, she should have been categorised as a high risk. She therefore did not have the correct level of supervision. On 2nd October 2022, Carol was found on the floor of her room, having been previously sat in her chair by staff. The fall was unwitnessed. Carol sustained a further hip fracture as a result of this fall. She was returned to hospital where further surgical fixation was carried out successfully. Initially, she recovered well post operatively, however, Carol developed Pneumonia. She had a RESPECT form in place from her earlier admission and therefore her care was comfort care only. Her Pneumonia progressed to Sepsis, and she died on 23rd October 2022 in hospital. �
Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: �
1a Multiorgan Failure
1b Sepsis
1c Pneumonia �
II�fixation of peri-prosthetic fracture of femur | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
University Hospitals Birmingham NHS Trust Mrs Clements� family
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Care Home Health related deaths
This report is being sent to: Birmingham Community Healthcare NHS Foundation Trust | |
23/11/2023 | 2023-0469 | Philip Malone | Birmingham and Solihull | Chief Executive, Birmingham and Solihull Mental Health Foundation Trust.
NHS Birmingham and Solihull Integrated Care Board.
The Rt Hon Victoria Atkins MP, Secretary of State for Health and Social Care. | On 13 July 2023 I commenced an investigation into the death of Philip Laurence Justin MALONE. The investigation concluded at the end of the inquest on 14 November 2023. | Mr Malone was diagnosed with treatment resistant schizophrenia in 1983 and had been sectioned multiple times. In May 2023 he was diagnosed with adult autism. At a review on 31 May he was considered to be stable. On 15th June a routine clozapine review identified sub-therapeutic levels but this was not notified to his clinicians. Sub-therapeutic levels of clozapine are likely to have contributed to a worsening in his symptoms. Around 24th June he was noted to have suffered a significant deterioration � with symptoms of thought disorder, anxiety, and responding to hallucinations � and following a mental health act assessment on 28th June clinicians wanted to detain him under section 2. No inpatient psychiatric bed was available. Whilst he awaited a bed, he remained in the community with daily visits from the mental health team. Last contact was on 1st July when he accepted his medication and appeared more settled. There was no answer when he was visited on 2nd July. His room at supported accommodation was entered on 3rd July and he was found deceased [REDACTED]. Recently he had expressed no suicidal ideation. Post-mortem examination confirmed the medical cause of death was: �
1a Cervical spinal cord injury.
1b Laceration [REDACTED]
1c
II The conclusion of the inquest was that death was the consequence of suicide. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
Mr Malone�s family.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015)
This report is being sent to: Birmingham and Solihull Mental Health Foundation Trust | NHS Birmingham and Solihull Integrated Care Board |Department of Health and Social Care | |
14/03/2023
| 2023-0097 | Nicola Norman | Inner West London
| Chief Executive, Central and North West London (CNWL) NHS Foundation Trust,
Trust Headquarters, Executive Office, 350Euston Road, London. NWl 3AX | On the 27th April 2021, 22nd and 23rd November 2022, evidence was heard touching the death of Nicola Norman. She had died on 20th January 2020, aged 42 years. �
Medical Cause of Death �
1 (a) Asphyxia
(b) Suspension by neck �
11 � How, when, where the deceased came by her death: �
Nicola had a 20 year history of mental illness and had been diagnosed with Emotionally Unstable Personality Disorder. From around November of 2019 she suffered a sharp decline, developing depression, anxiety and somatisation. Between December 2019 and January 2020she self-harmed on multiple occasions. Despite care of the primary health services and secondary health services, 20/01/2020 at approximately 10:30, she was found dead hanging at her mother�s address and recognised life extinct by the London Ambulance Service. There were no suspicious circumstances.
Conclusion of the Coroner as to the death: �
She took her own life whilst suffering severe and enduring mental illness. | CIRCUMSTANCES OF DEATH �
Extensive evidence was taken and accepted by the court.
In summary, of relevance to this report:
On 21/12/2019 Ms Norman called the Single Point of Access (SPA) in a highly anxious state and informed the operative that she had had enough of life and felt like burden. Ms Norman then disconnected the call. There was no FU by SPA
�
On 31/12/2019, Ms Norman spoke to the Single Point of Access (SPA) and informed them that she had taken an overdose and cut her wrists in front of her son. No suicidality assessment nor clinical assessment was undertaken by the SPA operative that she spoke to and she was simply told to ring primary care mental health services, as she was already under their care. She was not put through to this service by SPA, nor were any concerns about her passed on by SPA to any other service, including no concerns being passed by SPA to her GP.
�
Each of these calls were answered by administrators with no clinical qualifications.
�
Evidence was taken in court from the Service Manager representing SPA on these matters. Calls are apparently taken initially by non-clinical staff. They should call back if cut off as on 21/12/2019, and now �warm transfer� calls such as that of the 31/12/2019 to the service already providing care to the caller. | 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. | Suicide (from 2015)
| Central and North West London NHS Foundation Trust |
16/02/2024 | 2024-0087 | Roberto Bottello | Inner West London | Chief Executive, Central and North West London NHS Foundation Trust.
Commissioner of the Police of the Metropolis Chief Executive
NHS England | From the 22nd January until 1st February 2024, evidence was heard before a jury touching the death of Mr Roberto Bottello. He had died on the 16th September 2020, aged 44 years. �
Medical Cause of Death �
1 a. Multiple Injuries � �
How, when, where and in what circumstances the deceased came by his death: �
Roberto Bottello had been suffering problems with depression, anxiety and panic attacks in the months leading up to his death. On the 25th August 2020 he attended the urgent care centre at Hillingdon Hospital presenting with sleeplessness and visual hallucinations. He was referred to the psychiatric liaison nurse and discharged to be followed up by Addiction Recovery Community Hillingdon (ARCH). This referral was followed by 2 GP referrals and a self referral, He was not seen or assessed by ARCH prior to his death. �
Over the 13th and 14th of September 2020, Roberto presented to police officers on 4 occasions, presenting with paranoia. These presentations resulted in 3 Merlin reports of Adult Come to Notice made by police, which were on Roberto�s psychiatric record by 15th September 2020. Roberto�s last contact with his family was a telephone call on 14th September 2020. At around 21:00 on 14th September Roberto�s mother called the Single Point of Access (SPA) and was advised to report him missing. His parents reported Roberto missing to police at around 10:00 on 15th September 2020, and a missing person report was made.
�
Roberto came to the attention of police when he was in Berkely Square, London at around 00:10 on 16th September 2020. He was acting in an acutely disturbed manner. Hs body was tense, he was grinding his teeth and largely unresponsive. He had no shirt or shoes on. He began screaming at the sky. The police officers suspected ABD/ excited delirium. Roberto charged at the police officers. One officer pushed him back with an open hand and both officers challenged him with their taser red dot. He then became calm again. Further police officers and an ambulance attended Roberto.
�
After further agitation, Roberto was placed in handcuffs, place in an ambulance, and then his legs were placed in restraints. He was detained under section 136 of the Mental Health Act (MHA) and was transported to St Mary�s Hospital by ambulance.
�
At hospital, Roberto remained under guard by 2 police officers. The police liaise with the SPA to try to find a s.136 suite for Roberto. Roberto was medically cleared by 03.20 by the Accident and Emergency (A&E) doctors and he was referred to psychiatric liaison at 03.26. The differential diagnosis at the time of referral to psychiatric liaison was that Roberto was not intoxicated and was experiencing an acute psychotic episode.� Roberto was seen by psychiatric liaison at 03.55 and referred to the psychiatrist for a MHA assessment at 04.34. A place was made to defer the MHA assessment until after 09.00. The deferral of the assessment was reasonable based on his presentation and past history as known to the psychiatric team at the time.
�
Roberto�s identification was unclear to the police in the hospital, the SPA agents and hospital staff. Inadequate steps were taken to identify Roberto until his identity was established by the psychiatric liaison nurse prior to 04.34.
Identification details were passed to police at the hospital but there were missed opportunities to clarify his identity, especially in the final call between police and the SPA. The SPA and Hillingdon bed manager made assumptions about his identity.
�
If a s.136 suite had been made available to Roberto he would have been transferred but there is uncertainty about whether he would have been transferred before the time at which he fell from the window.
�
The SPA asked police officers to contact bed managers in an attempt to secure a
s.136 suite for Roberto, against the policy at the time that the SPA find the suite.
�
At the time of the incident that led to his death, Roberto was in cubicle 5 in St Mary�s Hospital. 2 police officers and one emergency departmental lead registrar were with him.
�
At around 06.00 Roberto began to show agitation again. An A&E nurse was dismissive about his behaviour. At around 06.20 he took his remaining clothes off and also took his medical stickers off.� He was spoken to by the police officers who asked him if he wanted to go to the toilet. An officer called a doctor to help who entered cubicle 5 with the officer.
�
From the 22nd January until 1st February 2024, evidence was heard before a jury touching the death of Mr Roberto Bottello. He had died on the 16th September 2020, aged 44 years. �
Medical Cause of Death �
1 a. Multiple Injuries � �
How, when, where and in what circumstances the deceased came by his death: �
Roberto Bottello had been suffering problems with depression, anxiety and panic attacks in the months leading up to his death. On the 25th August 2020 he attended the urgent care centre at Hillingdon Hospital presenting with sleeplessness and visual hallucinations. He was referred to the psychiatric liaison nurse and discharged to be followed up by Addiction Recovery Community Hillingdon (ARCH). This referral was followed by 2 GP referrals and a self referral, He was not seen or assessed by ARCH prior to his death. �
Over the 13th and 14th of September 2020, Roberto presented to police officers on 4 occasions, presenting with paranoia. These presentations resulted in 3 Merlin reports of Adult Come to Notice made by police, which were on Roberto�s psychiatric record by 15th September 2020. Roberto�s last contact with his family was a telephone call on 14th September 2020. At around 21:00 on 14th September Roberto�s mother called the Single Point of Access (SPA) and was advised to report him missing. His parents reported Roberto missing to police at around 10:00 on 15th September 2020, and a missing person report was made.
�
Roberto came to the attention of police when he was in Berkely Square, London at around 00:10 on 16th September 2020. He was acting in an acutely disturbed manner. Hs body was tense, he was grinding his teeth and largely unresponsive. He had no shirt or shoes on. He began screaming at the sky. The police officers suspected ABD/ excited delirium. Roberto charged at the police officers. One officer pushed him back with an open hand and both officers challenged him with their taser red dot. He then became calm again. Further police officers and an ambulance attended Roberto.
�
After further agitation, Roberto was placed in handcuffs, place in an ambulance, and then his legs were placed in restraints. He was detained under section 136 of the Mental Health Act (MHA) and was transported to St Mary�s Hospital by ambulance.
�
At hospital, Roberto remained under guard by 2 police officers. The police liaise with the SPA to try to find a s.136 suite for Roberto. Roberto was medically cleared by 03.20 by the Accident and Emergency (A&E) doctors and he was referred to psychiatric liaison at 03.26. The differential diagnosis at the time of referral to psychiatric liaison was that Roberto was not intoxicated and was experiencing an acute psychotic episode.� Roberto was seen by psychiatric liaison at 03.55 and referred to the psychiatrist for a MHA assessment at 04.34. A place was made to defer the MHA assessment until after 09.00. The deferral of the assessment was reasonable based on his presentation and past history as known to the psychiatric team at the time.
�
Roberto�s identification was unclear to the police in the hospital, the SPA agents and hospital staff. Inadequate steps were taken to identify Roberto until his identity was established by the psychiatric liaison nurse prior to 04.34.
Identification details were passed to police at the hospital but there were missed opportunities to clarify his identity, especially in the final call between police and the SPA. The SPA and Hillingdon bed manager made assumptions about his identity.
�
If a s.136 suite had been made available to Roberto he would have been transferred but there is uncertainty about whether he would have been transferred before the time at which he fell from the window.
�
The SPA asked police officers to contact bed managers in an attempt to secure a
s.136 suite for Roberto, against the policy at the time that the SPA find the suite.
�
At the time of the incident that led to his death, Roberto was in cubicle 5 in St Mary�s Hospital. 2 police officers and one emergency departmental lead registrar were with him.
�
At around 06.00 Roberto began to show agitation again. An A&E nurse was dismissive about his behaviour. At around 06.20 he took his remaining clothes off and also took his medical stickers off.� He was spoken to by the police officers who asked him if he wanted to go to the toilet. An officer called a doctor to help who entered cubicle 5 with the officer.
�
They tried to calm Roberto and talk to him. He became more agitated. A police officer asked him to move back on the bed.
�
Roberto started rocking on the bed, which was level with the windowsill. He put his foot on the sink and rolled himself backwards and moved himself onto the sill. He kicked the window and broke the glass. He moved himself backwards through the window. He was cut by broken glass as he exited the window. He fell 25 feet to the canal path below.
�
Roberto�s state of mind at the time, insofar as it may be determined, was that he was psychotic and in a state of agitation. He would not have acted as he did if he had not been psychotic.
�
After Roberto exited the window, there was a short delay before medical staff reached him because a gate was locked. He was attended by medical staff and the two police officers on the canal path.
�
As a result of the incident, Roberto suffered injuries:
cuts, bruises and grazes;
injuries to his limbs;
his lift upper limb suffered a large cut and his axillary vein and artery were divided;
he lost a large amount of blood; and
both of his lungs collapsed
�
Roberto was given CPR. He was administered adrenalin and regained a pulse. He was given a bilateral theracostomy. The trauma surgeon was alerted at 06.31. Roberto was transferred from the canal path to the emergency department. He proceeded directly to the surgical department. His blood vessels were clamped. He was given a blood transfusion. He lost circulatory output. He was given further CPR and shocked twice. He had minimal heart function and suffered cardiac arrest. His heart rhythm had become incompatible with life.
�
Roberto Bottello�s death was announced at 07.27 on 16th September 2020.
�
Matters which may have possibly caused or contributed to Roberto Bottello�s death:
�
The following matters may have possibly caused or contributed to Roberto�s death:
�
Cubicle 5 in which Roberto was placed in hospital was inadequate and unsuitable because it was a rm with windows rather than a designated mental health cubicle, and the bed was next to the windowsill and at the same or similar level. There were no effective measures in place to prevent patients breaking or exiting through the windows, notwithstanding that the windows were compliant with the legal requirements at the time.
There was insufficient communication between various parties involved, including:
The SPA and police;
A&E and the psychiatric liaison team;
Psychiatric liaison team and police;
Within the psychiatric liaison team;
The Hillingdon bed manager and the SPA and Central Flow Hub; and
The Hillingdon bed manager and the police.
�
The information management systems involved were inefficient and inadequate.
�
Roberto was not cared for by a Registered Mental Health Nurse (RMN) but was cared for by police officers, who are not mental health specialists. There was insufficient RMN provision at the time. An RMN would have been better placed than police officers to monitor Robert�s mental state, identify any issues such as increased agitation and developing risks.
�
The confusion of Roberto�s identity with a patient who had just been discharged from Hillingdon and the section 136 suite being made unavailable to him.
�
The apparent lack of available s.136 suites.
Conclusion of the Jury as to the death:
�
Roberto Bottello was experiencing an acute psychotic episode. He was detained under
s.136 of the Mental Health Act. he broke the window of his hospital cubicle with his feet and exited the window falling to the canal path below. In doing so, he suffered multiple injuries including cuts from broken glass that divided his axillary vein and artery and led to his death. | Extensive evidence was taken during the inquest from multiple live witnesses, written statements, reports, body worn footage and recordings of telephone calls between the police and SPA. Please see the extensive findings made by the jury in this case as set out above.
�
Of relevance to this report:
�
It was clear from the evidence that SPA were asking police officers to ring around various s. 136 suite providers to try and find a space for him, against policy at that time.
�
That a suite was available in Hillingdon that had not been declared as vacant as it should have been against policy.
�
That this space should have been made available to Roberto and it was not against policy.
�
This meant that the Central Flow Hub advised the psychiatric liaison nurse that there were no spaces available in London and as such the psychiatric liaison nurse drew up management plans that centred on getting Roberto�s required Mental Health Act assessment undertaken by the psychiatric liaison team, which is often slow and difficult to arrange, rather than having the option to consider transferring him more promptly to a section 136 suite.
�
That identification assumptions were made by the Hillingdon Bed manager and SPA based solely upon his sex and a similar first name to a person who had been discharged earlier in the day by Hillingdon that the person discharged was Roberto.
�
This identification assumption could have been easily put aside even with the minimal identification evidence being sought, but staff at Hillingdon, and SPA did not do this.
On this basis Roberto was refused a space in Hillingdon against policy, which he should have been allowed access to, even if had been the person with whom he had been confused who had just been discharged.
�
SPA staff colluded with the actions of the bed manager even though they knew it was against policy.
�
Simple identification checks that could have been made were not.
For example using the international phonetic alphabet in relation to Roberto�s surname in communication between police and SPA staff, and relying on numeric date of birth rather than using the name of the month. Both police and SPA staff did this which caused delay in identification.
�
The manager of SPA and Central Flow Hub at the time stated that she was completely unaware that staff were acting against training and policy.
�
The court had experienced immense difficulty in getting evidence from CNWL in relation to the Hillingdon issues despite repeated requests, such that the evidence was not clarified until the last day of evidence and after further directions had been give live in court. This was in my view a failure of the duty of candour by CNWL.
�
The court was grateful to the current senior manager from CNWL who worked over the weekend to secure the evidence that the court had been requesting for years.
�
It was also clear to the court and jury that the evidence of SPA witnesses was at times not credible despite recordings of the calls they made and transcripts of these calls being used as part of the evidence.
�
There were clearly issues in relation to communications at all levels as set out by the jury.
�
There were obvious errors made by SPA staff in relation to how they search their computer systems to identify individuals.
�
Together these matters meant that a section 136 suite was not made available to Roberto that should have been and it was possible that this contributed to his death.
�
The psychiatric liaison nurse did not share the assessment and differential diagnosis made by the A&E doctors with the psychiatric registrar. This was especially poignant in this case as it became clear that Roberto was not intoxicated at the time and was psychotic, rather than his symptoms being due to acute intoxication with drugs and/or alcohol as was assumed by the psychiatric liaison nurse and passed to the psychiatric registrar. The A&E doctor had diagnosed Roberto correctly some hours before his death and medically discharged Roberto. This was recognised by the psychiatric registrar, who is now a consultant, as a point of learning for her and psychiatric liaison.
�
All witnesses confirmed that there are at times still shortages of section 136 suites and heavy demand from psychiatrically unwell people despite definite improvements in service.
�
Further that most s136 incidents occur out of hours when there is less resource to manage them from psychiatric services.
�
Evidence from the psychiatric doctor was that there are severe resource shortages in the area in which she now works with up to 50% of psychiatric nursing staff posts being vacant.
There is now direct access by police on many occasions to section 136 suites within London, a practice that could be adopted nationally, with general improvement in service provision.
�
Extensive evidence was taken in relation to the window through which Roberto had exited to his death. This window was consistent with building regulations but film has now been applied by Imperial to windows in situations where disturbed persons may be more at risk of smashing them to make these windows more difficult to smash and if they do, then be less likely to shatter and cause lacerations. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
Father of Mr Bottello
[REDACTED]
�
Chief Executive,
Imperial Health Care Trust
�
IOPC
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Central and North West London NHS Foundation Trust | Metropolitan Police Service | NHS England | |
09/06/2023 | 2023-0189 | Elsie Murphy | Cumbria | Chief Executive, Cumberland Council, Carlisle | On 30 September 2022 I commenced an investigation into the death of Elsie Mary MURPHY, aged 86. The investigation concluded at the end of the inquest . The conclusion of the inquest was
Death due to an accident
1a Acute on-chronic sub-dural haemorrhage
1b
1c Fall
II Anticoagulated for atrial fibrillation | On 27th September 2022 Elsie was walking along the footpath from that leads from Windermere Road to Ewanrigg Road in Maryport to reach a bus stop. immediately below the steps leading up to Ewanrigg road the path turns 90 degrees right, Elsie slipped in a puddle that had formed here and fell, sustaining her fatal injury. She died in Cumberland Infirmary the following day. | I have sent a copy of my report to the Chief Coroner and to the following Interested
Person , Elsie�s daughter.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 | |
18/04/2023 | 2023-0119 | Keith Hodson | Herefordshire | Chief Executive, Hereford County Hospital | On 20 July 2022, I commenced an investigation into the death of Keith Hodson, aged 68 years . The investigation concluded at the end of the Inquest on 5 April 2023. The conclusion of the Inquest was narrative (see 4 below). | Mr Hodson had a complex medical history. There were delays prior to an ambulance being called, in connection with the attendance of the ambulance, on admission to hospital and subsequently in connection with appropriate treatment. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; [REDACTED].
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Hereford County Hospital | |
08/12/2023 | 2023-0515 | Lindy Aston | Leicester City and South Leicestershire | Chief Executive, Kettering General Hospitals NHS Trust via their legal representatives. | On 21 October 2021 I commenced an investigation into the death of Lindy Lyanne ASTON aged 67. The investigation concluded at the end of the inquest which took place on 9, 10, 11 and 24 November 2023. The conclusion of the inquest was that: �
Narrative Conclusion Mrs Aston was a 67 year old female who appropriately underwent a successful total gastrectomy for stomach cancer at the University Hospitals of Leicester NHS Trust on 29 September 2021. Post operatively, whilst at home on 15 October 2021, Mrs Aston suffered a ruptured spleen which requires surgical treatment. Mrs Aston was taken to Kettering General Hospital where, for reasons we don�t understand, surgery did not take place, instead she was kept on the ICU and transferred to the Leicester Royal Infirmary on 16 October 2021 where she underwent surgery but died on 18 October 2021 at 12:40hrs. The cause of death was established as: I a Multi Organ Failure I b Ruptured spleen following a total gastrectomy I c � II | Mrs Aston was a 67 year old female who underwent a total gastrectomy for stomach cancer at the University Hospitals of Leicester NHS Trust on 29 September 2021. On 15 October 2021 Mrs Aston began to experience pain in her abdomen, this became progressively worse. EMAS attended and Mrs Aston was transported by emergency ambulance to Kettering General Hospital.
�
Mrs Aston was initially treated in the Accident and Emergency Department at Kettering General Hospital before being placed on the ICU. She remained at Kettering for almost 24 hours until she was transferred to the University Hospitals of Leicester NHS Trust.
�
On 16 October 2021 Mrs Aston arrived at the Leicester Royal Infirmary at 16:00hrs, she was taken to theatre at 16:10hrs and underwent a splenectomy operation. Mrs Aston remained very unwell post-operatively and died on the 18 October 2021 at 12:40hrs. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
The Aston Family
The University Hospitals of Leicester NHS Trust
�
I have also sent it to
�
The CQC
�
who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Kettering General Hospitals NHS Trust | |
14/08/2023 | 2023-0290 | Marie Zarins | Leicester City and South Leicestershire | Chief Executive, Leicestershire Partnership NHS Trust (via their legal representatives) | On 02 December 2021 I commenced an investigation into the death of Marie ZARINS aged 42. The investigation concluded at the end of the inquest which took place on 13 and 14 July 2023.
The conclusion of the inquest was: �
Suicide �
The cause of death was established as: I a Hanging (suspension by ligature) | Miss Zarins was a 42 year old female who was reported missing by her family and discovered suspended�[REDCATED], Leicestershire. Her death was confirmed at the scene by one of the attending paramedics on 24 November 2021 at 16:04hours. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
1.��[REDACTED], father and mother of the Deceased
2.�[REDACTED] , brother of the Deceased
3.�[REDACTED] , partner of the Deceased
4.��Leicestershire Partnership NHS Trust (via its legal representatives)
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015)
This report is being sent to: Leicestershire Partnership NHS Trust | |
25/06/2024 | 2024-0339 | John Howe | Manchester South | Chief Executive, Manchester City Council
Chief Executive, East Midlands Ambulance Service
Group Chief Executive Manchester University NHS Foundation Trust | On 2nd June 2023 an investigation was commenced into the death of John Howe, then aged 81 years. The investigation concluded at the end of the inquest on 24th May 2024. At the end of the Inquest, I recorded a narrative conclusion that Mr Howe died as a result of hospital acquired pneumonia against a background of necessary surgery to treat diabetic foot sepsis. | John Howe was an 81-year-old man with type 2 diabetes and peripheral vascular disease. His diabetes was not always controlled, and he had frequent episodes of high blood sugar. In December 2021 he started to experience issues with his foot including sepsis as a result of the diabetes and peripheral vascular disease. His foot deteriorated and by October 2022 he was advised that amputation was necessary, but he did not consent to this. �
During an admission on 28th April 2023, it was discovered that his condition had deteriorated, and he agreed to an amputation which took place on 10th May 2023 at Manchester Royal Infirmary. He was discharged home on 19th May 2023 but thereafter he deteriorated and was admitted to Stepping Hill Hospital, Poplar Grove Stockport on 23rd May 2023. Despite treatment he continued to deteriorate and died there on 28th May 2023 as a result of hospital acquired pneumonia against a background of necessary surgery to treat the diabetic foot sepsis and haemorrhage from the wound. �
The Inquest heard that when Mr Howe was discharged from hospital on 19th May 2023, and he was woken from sleep at 23:00 to be transported home meaning that he arrived at his home address in the early hours of the morning on 20th May 2023. His family were not aware that this was happening, access to his home was difficult, and it resulted in him being left outside whilst this was addressed.
�
A serious Incident Review took place, and a report was prepared after a lengthy delay. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
[REDACTED] on behalf of the family and Stepping Hill 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.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of 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: Manchester City Council | East Midlands Ambulance Service | Manchester University NHS Foundation Trust | |
20/06/2023 | 2023-0201 | Anita Graves | Manchester South | Chief Executive, Medicines and Healthcare products Regulatory Agency | On 27th January 2023, an investigation was commenced into the death of Anita Graves, aged 92 years. The investigation concluded at the end of the inquest on 30th May 2023. The outcome of the inquest was that the medical cause of the death of Mrs Graves was: 1a. Urinary Tract Infection 1b. E.Coli 2 Hyperthyroidism �
The conclusion was that she died from E.Coli infection following treatment for hyperthyroidism. | Mrs Graves was diagnosed with hyperthyroidism in 2019. Her condition was monitored by specialists from the Endocrinology Team at the local hospital and regulated by carbimazole and propranolol. The regular dose of carbimazole in particular, was adjusted periodically by Mrs Graves� GP in light of regular reviews of blood test results under the supervision and guidance of the Endocrinology Team.
An unusually abnormal blood test result in early December 2022 revealed that Mrs Graves� thyroid had rapidly and unexpected become underactive. The clinical decision was taken to discontinue temporarily the carbimazole and propranolol medication pending analysis of repeat blood tests which were scheduled for early January 2023. By 22nd December 2022, Mrs Graves� thyroid had become overactive again and resulted in an emergency admission to hospital for treatment. Carbimazole and propranolol were re-started and by 30th December 2022, the FT4 had dropped from 116.6 to 64.8, reflecting a significant improvement in thyroid hormones.
Mrs Graves remained in hospital, suffering a persistently high heart rate during her admission and developed an E.Coli urinary tract infection, which did not respond to treatment and brought about her death on 4th January 2023.
The evidence at the inquest revealed that carbimazole is dispensed in 5mg, 10mg and 20mg tablet forms, which are visually virtually impossible to distinguish from each other. The adjusted doses periodically required different daily combinations of these tablets to achieve the correct prescribed dose. Compounding the potential confusion of differing strengths of tablets was their visual similarity to aspirin, which was also part of Mrs Graves regular prescription and the variety of packaging (unmarked pharmacy boxes and different manufacturer�s packaging, for example) in which the carbimazole tablets were dispensed by the community pharmacy.
The inquest found that Mrs Graves had inadvertently taken more than the prescribed dose of carbimazole which had caused the sudden underactive thyroid in early December 2022.
The ongoing potential confusion of the differing strengths of carbimazole tablets was highlighted by both the specialist Endocrinology Team pharmacist and consultant during the evidence notwithstanding that this issue had been recognised and the subject of national guidance historically.
Whilst Mrs Graves� hyperthyroidism was not the direct cause of her death, it was a significant contributory condition and the inadvertent increased dose of carbimazole had been the precipitating factor in her hospitalisation and was the background to her inability to fight the infection from which she died. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1) [REDACTED] (next of kin to Mrs Graves);
2) Marple Medical Practice; and
3) Endocrinology and Pharmacy Department of Stepping Hill Hospital.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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
This report is being sent to: Medicines & Healthcare products Regulatory Agency | |
27/02/2017 | 2024-0220 | Rachel Edwards | Suffolk | Chief Executive, Norfolk and Suffolk NHS Foundation Trust | On 15th May 2017 I commenced an investigation into the death of Rachel Holly Edwards. �
The investigation concluded at the end of the Inquest on 22nd February 2018, The conclusion of the inquest was that Rachel Edwards died as the result of an overdose of her prescription medicines following a seven year period of suffering from severe and unbearable pain, the result of injuries sustained in a fall from height in 2009. �
The medical cause of death was confirmed as: �
i(a) Overdose of multiple drugs. | Rachel died on the 8111�May 2017as the result of an over dose of mum le prescription medicines at her home address [REDACTED], Suffolk. �[ A concerned friend had been unable to contact her when visiting Rachel�s home and had called her family. Rachel�s father Chris arrived at a short while later w1th a spare key to the property, entered and subsequently found his daughter fully clothed but unresponsive in the bath. � The emergency services were caned and upon arrival of a paramedic Rachel�s death was recognised at 08.39 on the 8h1 May 2017. | I have sent to the Chief Coroner and to the following Interested person.
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 Area 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: Norfolk and Suffolk NHS Foundation Trust | |
25/09/2023 | 2023-0352 | Brian Moreton | Newcastle upon Tyne and North Tyneside | Chief Executive, North Cumbria Integrated Care NHS Foundation Trust, Pillars Building, Cumberland Infirmary, Infirmary Street, Carlisle, Cumbria ,CA2 7HY. | On 5th April 2023 an inquest was opened into the death of Brian David MORETON. On 21st September 2023 I resumed the inquest.
I concluded that Brian David MORETON died on 6th May 2022 at Freeman Hospital, Newcastle Upon Tyne from; �
1a Cytomegalovirus colitis and invasive aspergillosis
1b Treatment of immune checkpoint inhibitor colitis
1c lmmunotherapy for metastatic malignant melanoma �
I recorded a Narrative Conclusion together with a finding of Neglect. | CIRCUMSTANCES OF DEATH �
Brian Moreton was admitted to the Cumberland Infirmary on 2nd March 2022 with diarrhoea, recurring fever and a distended abdomen. A toxic mega colon was found on the evidence to have been present on CT imaging at that time, but was not reported to those treating him. He was treated over the following month with high dose immuno suppressants designed to treat a severe colitis without improvement. On 2nd April 2022 he was transferred to the Freeman Hospital, Newcastle Upon Tyne, where it was seen his bowel had perforated., He received surgery and remained very seriously ill. He developed various infections due to his immuno suppressed state and died from these infections on 6th May 2022. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Brian David MORETON via their solicitors Messrs Irwin Mitchell
Chief Executive, Newcastle Upon Tyne Hospitals NHS Foundation Trust via their solicitors Messrs DAC Beachcroft
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: North Cumbria Integrated Care NHS Foundation Trust | |
04/04/2023 | 2023-0116 | Thomas Jayamaha | Nottinghamshire | Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust
Lead Commissioner for mental health services, Nottinghamshire Integrated Care Board | On the 1st March 2022, I commenced an investigation into the death of Thomas Jayamaha. The investigation concluded at the end of the inquest on the 15th March 2023 � The conclusion of the inquest was Suicide | Tom took his own life on by taking Pentobarbitol, that he had ordered from a website abroad. He had Autism Spectrum Disorder (ASD), and a long history of suicidal ideation, with previous self harm/suicide attempts. He was aged twenty three when he died. �
Tom had long term mental health difficulties, and he was repeatedly referred to the Nottinghamshire Healthcare NHS Foundation Trust by his GP, with the GP asking for ongoing psychological support, as Tom was considered too great a risk for him to be seen by Primary Mental Health services. �
He had a number of factors in his life that made him vulnerable to low mood and suicidal ideation, including his ASD diagnosis, a history of sexual abuse, difficulties in his family relationships, and that he was in a long term coercive and controlling relationship, that was not understood by Trust staff. �
Tom was also unaware of the local mental health team treatment plan for him when he died, and reportedly felt that the Trust could not help him as referrals were repeatedly rejected by teams across the Trust. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
1.��[REDACTED], Parents of Tom
2. [REDACTED]
3.�The GP, [REDACTED]
4. Nottingham City Council (for the attention of the Adult Safeguarding service)
5.� [REDACTED] The Human Flourishing Project
6.� [REDACTED] The Tomorrow Project
7.� [REDACTED] Nottinghamshire Sexual Violence 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. | Suicide (from 2015)
This report is being sent to: Nottinghamshire Healthcare NHS Foundation Trust and Nottinghamshire Integrated Care Board | |
18/7/2024 | 2024-0383 | Paul Roberts | North Wales (East & Central) | Betsi Cadwaladr University Health Board, [REDACTED] | On the 29th of August 2023 I commenced an investigation into the death of Paul Anthony
Roberts (DOB 16.4.62 DOD 15.8.23). The investigation concluded at the end of the inquest on
the 17th of July 2024. The cause of death was recorded as being due to 1(a) Knife Injury to heart and the conclusion of the inquest was one of misadventure as although this was a self-inflicted injury there was evidence to support the view that it was not by way of an intention to end his life. | In February 2023 the deceased took an overdose and inflicted multiple stab wounds to himself. He had a referral to mental health services and an initial assessment by the
home treatment team who then passed his care to the local primary mental health support service (LPMHSS). At this time his case was effectively �lost in the system� and he received no further mental health support.
On the 14th of August 2023 he attended the emergency department (ED) at Glan Clwyd Hospital due to concerns around a further deterioration in his mental health. Although he was triaged, no referral for a psychiatric assessment was made for a number of hours and by the time that this error was rectified and psychiatric liaison attended the ED, Mr Roberts had left the department.
The following day he harmed himself by way of multiple wounds and died as a result of the same. | 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. | Mental Health related deaths�| Hospital Death (Clinical Procedures and medical management) related deaths | Wales prevention of future deaths reports (2019 onwards)�
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This report is being sent to: Betsi Cadwaladr University Health Board | |
24/11/2023 | 2023-0471 | Hazel Pearson | North Wales East and Central | Betsi Cadwaladr University Local Health Board | On 6 December 2021 an investigation was commenced into the death of Hazel Pearson (DOB 28/6/42) who died on 30 November 2021. The investigation concluded at the end of the inquest on 23 November 2023. The conclusion of the inquest was a narrative conclusion as follows : �
Misadventure contributed to by neglect | The circumstances of the death are as follows : �
Hazel Pearson was admitted into Ysbyty Maelor hospital on 20/8/21 having spent some time at a care home and community hospital before returning to Ysbyty Maelor hospital on 23/11/21. She had known coeliac disease which was recorded on her medical records. Her family had repeatedly informed staff about her coeliac disease. On 26/11/21 she was offered and consumed Weetabix probably believing it was a gluten free equivalent. This caused her to vomit, aspirate, suffer significant oxygenation and subsequent respiratory deterioration which then led to her death from aspiration pneumonia. She died on 30/11/21 at Ysbyty Maelor, Wrexham. | 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. | Care Home Health related deaths
This report is being sent to: Betsi Cadwaladr University Health Board | |
26/04/2023 | 2023-0137 | Nancy Price | North Wales East and Central | Betsi Cadwaladr University Local Health Board | On 11 January 2021 an investigation was commenced into the death of Carolyn Nancy Price (DOB 3/6/1958) who died on 1 January 2021. The investigation concluded at the end of the inquest on 25 April 2023.
The conclusion of the inquest was a narrative conclusion as follows : �
Nancy Carolyn Price died on 1 January 2021 at Ysbyty Glan Clwyd. There was a delay in assessing her and transferring her from Ysbyty Maelor to Ysbyty Glan Clwyd to the extent that there were missed opportunities for her to undergo timely and possible life saving surgery. | The circumstances of the death are as follows : �
Nancy Carolyn Price, aged 62 at the time of her death, presented to the Emergency Department of Wrexham Maelor Hospital on 30 December 2020 via ambulance which had arrived at her home at 16:37. She had sudden onset of movement and sensation in both lower limbs since midday. She was eventually seen by a medic, at approximately 9.45pm, when limb ischaemia was diagnosed. In consultation with the on call vascular consultant at Ysbyty Glan Clwyd, where vascular services are centralised for the Health Board, urgent CT angiogram was advised, IV heparin and pain relief, and also urgent ambulance transfer to Ysbyty Glan Clwyd. Nancy Price arrived many hours later, at approximately 3am and required rehydrating prior to the surgery. The surgery was commenced at approximately 05:55. Following surgery she developed multi organ failure and died on 1 January 2021. | 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. | Hospital Death (Clinical Procedures and medical management) related deaths | Wales prevention of future deaths reports (2019 onwards)
This report is being sent to: Betsi Cadwaladr University Local Health Board | |
08/06/2023 | 2023-0185 | Eifion Huws | North West Wales | Betsi Cadwaladr University Local Health Board (BCUHB) | On 21 June 2022 an investigation was commenced into the death of Eifion Wyn Huws (DOB 25/4/59) who died on 10 June 2022. The investigation concluded at the end of the inquest on 7 June 2023.
The conclusion of the inquest was suicide. | The circumstances of the death are as follows : �
Eifion Wyn Huws was aged 63 at the time of his death on 10 June 2022. He had a past medical history of non-Hodgkin�s lymphoma having had the diagnosis on 12 January 2022 and poorer mental health as a result. Other than the lymphoma he had no other significant past medical history. The anticipation of awaiting scans and treatment impacted severely upon his mental health but he had significant family support. Eifion was regularly reviewed by a GP and medicated accordingly. He had previous attempts at self-harm by way of medication overdose or self-inflicted injury. He had been under the care of the Community Mental Health Team including Home Treatment Team and primary care since early 2022 up to his death. His acts of self-harm were impulsive but serious. On 10 June 2022 Eifion had left his home address to attend his daughter�s home across the road to let the cat out. There was a concern for Eifion when he did not reply to a text message from his wife around 15 mins later who then attended at their daughter�s home and on opening the front door found Eifion suspended by a ligature [REDACTED]. Eifion was confirmed as having passed away at the property on 10 June 2022 at 10.37 by an attending paramedic. | I have sent a copy of my report to the Family of the Deceased and to the Chief Coroner. I have also sent a copy to Eluned Morgan, Heath Minister.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Betsi Cadwaladr University Health Board | |
24/03/2023
| 2023-0102 | Richard Hill | Derby and Derbyshire
| Bill Sweeney, Chief Executive Officer, Rugby Football Union Rugby House Twickenham Stadium 200 Whitton Road Twickenham Middlesex TW2 7BA | On 10 May 2022 I commenced an investigation into the death of Richard James HILL, referred to as Richard for the purposes of the inquest, aged 24. The investigation concluded at the end of the inquest on 13 March 2023. The conclusion of the inquest was that Richard�s death was alcohol related. | Richard died on 30 April 2022 at a sports and recreation club where his rugby club was holding its annual awards ceremony. Richard had been drinking alcohol all day and at the event and by 21:23 when he collected his trophy he was clearly showing the effects of alcohol inebriation and this was apparent to people at the event, including club members. About thirty minutes later he was unable to walk and had reduced responsiveness and he had to be carried to an outside bench. When it was realised that he was possibly critically unwell an ambulance was called, although medically trained attendees at the club event had started to provide resuscitative interventions, including use of a defibrillator which identified there was no shockable rhythm. Paramedics attended but intensive resuscitation was sadly unable to revive Richard and he was pronounced dead at the scene. �
Richard was known to drink heavily when out with friends and at social events. The court heard evidence from Richard�s brother that Richard�s alcohol consumption appeared to increase following the death of a close friend in January 2022. �
After Richard�s death, as part of post-mortem examination, blood and urine samples were sent for toxicological testing. Toxicology identified a very high level of alcohol in Richard�s system, at a level capable of causing death due to alcohol toxicity. Cocaine was also identified in Richard�s system but was not considered to be contributory to his death. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
[REDACTED] (parents of Richard)
Ashbourne Rugby Union Football Club
[REDACTED] (licensee of the Ashbourne Recreation Ground)
�
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
| Rugby Football Union |
02/10/2023 | 2023-0360 | Paula Lenihan | Birmingham and Solihull | Birmingham & Solihull Mental Health NHS Foundation Trust. | On 16 May 2023 I commenced an investigation into the death of Paula LENIHAN. The investigation concluded at the end of the inquest. The conclusion of the inquest was:
�
Natural causes, contributed to by misuse of prescribed and controlled drugs. | On 06/03/2023 Paula Lenihan was found deceased at her home address. She had a complex medical history with both physical and mental health problems. Post mortem results revealed she had died as the result of heart disease and that she had a combination of drugs in her system suggestive of excessive use, or overdose. Together these may have caused toxicity but none were at levels which individually would have caused fatality. It is not possible to ascertain her state of mind shortly prior to her death, but when seen by her GP on 01/03/2023 no particular concerns had been noted.
Following a post mortem the medical cause of death was determined to be:
1a Ischaemic and hypertensive heart disease
1b
1c
I������� Combined toxicity [REDACTED] | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Paula
I have also sent it to the regional Medical Examiner, ICB, NHS England, CQC, who may find it useful or of interest.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Alcohol, drugs medication related death
This report is being sent to: Birmingham and Solihull Mental Health Foundation | |
02/01/2024 | 2024-0003 | Sylvia Nash | Birmingham and Solihull | Birmingham City Council,Connaught House Care Home | On 24 April 2023, I commenced an investigation into the death of Sylvia May NASH. The investigation concluded at the end of the inquest on 25th September 2023 . The conclusion of the inquest was; Accident | On 11th March 2023, the deceased fell at The Orchards Nursing Home where she resided. She was taken to Birmingham Heartlands Hospital where she underwent surgical fixation of a fractured neck of femur sustained in that fall. Post operatively, she developed septic shock, and despite treatment, continued to deteriorate. She died in hospital on 14th April 2023. �
Based on information from the Deceased�s treating clinicians the medical cause of death was determined to be: �
1a Sepsis �
1b Prosthetic joint infection
1c
II��� Fractured neck of femur operated, Lewy Body Dementia | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
[REDACTED] � Daughter of Mrs Sylvia Nash 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: Birmingham City Council | Connaught House Care Home | |
12/07/2023 | 2023-0241 | Mohammed Hussain | Birmingham and Solihull | Birmingham and Solihull Mental Health Foundation Trust
Secretary of State for Health | On 5 January 2023 I commenced an investigation into the death of Mohammed Khalid HUSSAIN. The investigation concluded at the end of the inquest. The conclusion of the inquest was; � Natural causes | At around 01.30 on 28/11/22 Mr Hussain was found collapsed on the bathroom floor at his home address. An ambulance was called by his sister when she arrived at the property but sadly he was confirmed deceased at 02.09. He had been seen by his sister the day before when he was noted to be well. He had been diagnosed with treatment resistant schizophrenia and depression and had been under the care of Mental health team since 1997. He was established on clozapine in 2004 which requires monthly monitoring due to its potential toxic effects. His clozapine level was 904 ug/L on 03/05/22.
Arrangements were made to set up a review appointment and he continued to attend monthly for bloods tests. He was reviewed on the telephone on 14/10/22 when a decision was made to reduce his medication but this did not occur. At the time there were no signs of toxicity. He was seen by his care coordinator on 15/11/22 when no concerns were noted about signs of toxicity. Post-mortem toxicology showed a high level of clozapine � however his nor clozapine level was noted to be reducing in life and he had no signs of the toxic effects of this drug. �
Following a post mortem, the medical cause of death was determined to be: � 1a Sudden cardiac death in Schizophrenia | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: Mr Hussain�s family
I have also sent it to the regional Medical Examiner, ICS, NHS England, CQC, who may find it useful or of interest.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Other related deaths
This report is being sent to: Department of Health and Social Care | Birmingham and Solihull Mental Health Foundation Trust | |
15/03/2023
| 2023-0094 | Jai Singh | Birmingham and Solihull
| Birmingham and Solihull Mental Health Foundation Trust,
NHS England (Health and Justice),
and the Phoenix Partnership (Leeds) Ltd | On 1 February 2022 I commenced an investigation into the death of Jai SINGH. The investigation concluded at the end of the inquest on the 10th March 2023.
The conclusion of the jury at the inquest was; �
Suicide The following matters probably caused or contributed to Mr Singh�s death: The failings of safer custody to appropriately communicate and document family concerns to other staff within the prison.The failure to use interpretation services to effectively communicate with Mr Singh by both the custodial and the healthcare teams.
The failure to communicate relevant information within and between the custodial team and the healthcare teamThe failings to appropriately open, re-open and carry out the ACCT process.The failure to carry out sufficient and thorough welfare checks.That Mr Singh did not undergo an assessment for section 48 transfer.
A significant lack of rigor in respect to the completion of official prison and healthcare documentation.
That Mr Singh was not admitted to ward 2 and remained on a residential wing.
�
The following matters possibly caused or contributed to Mr Singh�s death:
Failings to heed and communicate family concerns by both the custodial team and the healthcare team.
The failure to allocate an individual community psychiatric nurse as a single point of contact following the opening of an ACCT. | Jai Singh died at City Hospital on the 28th January 2022 having been admitted after he was found in cardiac arrest in his cell at HMP Birmingham on the 27th January 2022. Mr. Singh had asphyxiated due to placing a bag over his head. He received CPR from prison staff and paramedics and was resuscitated but had suffered irreparable brain and organ damage.
Mr. Singh had been detained at HMP Birmingham on the 21st September 2021 whilst on remand awaiting trial for the murder of his wife. From the time of his admission Mr. Singh�s family were concerned that he was suffering from a severe mental health condition and raised this in numerous emails and telephone calls to safer custody. The content of calls and emails was not recorded on NOMIS casenotes for the information of the custodial team and was not consistently communicated to the mental health team. The information that was passed to the mental health team was not clearly recorded in the SystemOne �
journal for all clinicians to see. Consequently, the opportunity to identify risk and open an ACCT document was missed.
�
From an early stage Mr. Singh was reporting psychotic behaviour to community psychiatric nurses and was noted to be behaving unusually by custodial staff but he denied any active suicidal or self-harming thoughts. His cellmate and a Chaplain raised concerns about his behaviour but still an ACCT book was not opened.
�
On the 22nd November 2021 an ACCT book was opened after Mr. Singh reported wanting to kill himself. The ACCT assessment, reviews and care plan were deficient leading to the ACCT being closed prematurely on the 30th November 2021. The post closure process was also inadequate. During the time Mr. Singh was at HMP Birmingham he had a number of welfare checks due to family concerns but these were superficial and perfunctory and never carried out with an interpreter even though Mr. Singh�s English was poor. Consequently, his risk was not adequately assessed.
�
Following an assessment on the 3rd December 2021 a Consultant Forensic Psychiatrist instructed by Mr. Singh�s criminal defence team identified that Mr. Singh was suffering with auditory hallucinations, low mood, tiredness and suicidal ideation and made a diagnosis of schizophrenia with an effective element. The Psychiatrist made a referral to a secure inpatient unit, The Hatherton Centre, for a transfer under section 48 of the Mental Health Act. The referral was sent to the Hatherton Centre but was not sent to HMP Birmingham straightaway. The referral to the secure unit was not accepted because it was made by an independent psychiatrist rather than the prison�s mental health team. The mental health team at HMP Birmingham were, however, contacted on the 13th December 2021 by a psychiatrist from the Hatherton Centre who stated that there had been a request for assessment for transfer and asked for further information. He was given misleading information that Mr. Singh was �coping well� and therefore informed the mental health team that an assessment would not be carried out. No note was made of the conversation with the Hatherton Centre psychiatrist and no action was taken to investigate and pursue a section 48 transfer. The information provided by the independent Consultant Forensic Psychiatrist and the history of psychotic symptoms in SystemOne records ought to have resulted in an assessment by the Hatherton Centre. An assessment would have been likely to result in section 48 transfer. Whilst Mr. Singh remained at HMP Birmingham awaiting transfer he ought to have been under the care of the mental health team and housed on ward 2 (the mental health inpatient wing).
�
Mr. Singh continued to report that he was hearing voices, hallucinating, struggling to sleep and low in mood. He was reviewed by GPs at the prison on the 29th November, 13th December, 4th January and 25th January who prescribed antidepressants and sleeping medication which Mr. Singh reported were not working.
On the 14th January 2022 a prison Consultant Psychiatrist determined that Jai Singh required urgent admission to the inpatient psychiatric ward for assessment. However, the admission was not facilitated and Mr. Singh remained on a residential wing. The decision not to admit Mr. Singh to the ward was not recorded in his SystemOne records. Mr. Singh received no further input or support from the mental health team. When he was seen by a GP on the 25th January 2022 it was identified that medication was not helping and Mr.Singh needed to be seen by a psychiatrist but the GP thought he was going to be transferred to Ward 2 and therefore took no further action.
�
All actions taken following Mr. Singh being found in cardiac arrest on the 27th January 2022 were appropriate.
�
Following a post mortem the medical cause of death was determined to be:
�
1a Hypoxic-ischaemic brain damage 1b Multi-organ failure
1c Cardio-Pulmonary arrest due to asphyxia | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1)� The sisters of Jai Singh, [REDACTED]
2)� Children of Jai Singh, [REDACTED]
3)� Ministry of Justice (MOJ)
4)� Birmingham Community Health Care (�BCHC�)
5)� Birmingham and Solihull Mental Health Foundation Trust (�BSMHT�)
6)� Prisons and Probation Ombudsman (�PPO�)
7)� Midlands Partnership NHS Foundation Trust (�MPFT�)
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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
| Birmingham and Solihull Mental Health Foundation
Trust, NHS England, and Phoenix Partnership Ltd. |
19/08/2024 | 2024-0459 | Juliette Sewell | Birmingham and Solihull | Birmingham and Solihull Mental Health NHS Foundation Trust | On 23 April 2024 I commenced an investigation into the death of Juliette Kirsty SEWELL. The investigation concluded at the end of the inquest.
The conclusion of the inquest was; Suicide | In the afternoon of 16/02/2024, Juliette was discovered unresponsive in�[REDACTED] by a�family friend, surrounded by multiple empty packets of medications, and was subsequently confirmed deceased at 13:43. Post-mortem investigations indicated she had died from a� fatal overdose. Juliette had been missing since the evening of 14/02/2024 when she left� home following difficulties in her personal life and was last seen alive by a friend at around� 22:00 on 14/02/2024. Juliette was seen crying on the porch of her friend�s home on�Fallowfield Road before heading in the direction of [REDACTED]. She had a history of� mental health illness since 2010 and had been under the care of both her GP and her local� mental health team. At the time of her death, Juliette had been awaiting a follow-up� appointment with the mental health team since January 2023 which had been delayed due� to staffing shortages, but it is unlikely that her death could have been prevented.�
Following a post mortem, the medical cause of death was determined to be:
1a [REDACTED] and [REDACTED] toxicity
1b
1c
II Presence of [REDACTED], [REDACTED], [REDACTED], [REDACTED], [REDACTED] and [REDACTED]. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
[REDACTED] , Sister
I have also sent it to the Medical Examiner, ICS, NHS England, CQC, who may find it useful or of interest.�
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner. | Suicide (from 2015) | Birmingham and Solihull Mental Health NHS Foundation Trust |
08/11/2023 | 2023-0433 | Leya Adris | Birmingham and Solihull | Birmingham and Solihull Mental Health NHS Foundation Trust (�BSMHT�) and Birmingham and Solihull Intergrated Care System (�ICS�) | On 5 June 2023 I commenced an investigation into the death of Leya Amra ADRIS. The investigation concluded at the end of the inquest . The conclusion of the inquest was; Drug related | Miss Adris was pronounced deceased by paramedics at her sister�s home, [REDACTED], Birmingham, at 09:07 on the 18th March 2023 after she was witnessed to suffer an episode of fitting. Post mortem testing has identified that her death was due to [REDACTED] toxicity. Miss Adris had also taken excessive�[REDACTED]. Both medications are used for the management of anxiety but were not prescribed to her and therefore she may not have known the appropriate doses. Miss. Adris had recently sought support for increased anxiety and suicidal thoughts but denied any immediate intent. She had spent a lot of time with family in the days before her death and had made detailed plans [REDACTED] for the subsequent days. There was nothing to indicate that she was suicidal and is likely to have accidentally overdosed.
�
Following a post mortem the medical cause of death was determined to be:
�
1a Acute fatal toxicity
�
1b��[REDACTED] overdose
Mental Health issues | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: [REDACTED], next of kin.
�
I have also sent it to the CQC and�[REDACTED] who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Alcohol, drugs medication related deaths, Care Home Health related deaths
This report is being sent to: Birmingham and Solihull Mental Health NHS Foundation Trust | Birmingham and Solihull Integrated Care System | |
11/06/2023 | 2023-0190 | Marlene McCabe | Blackpool & Fylde | Bloomfield Medical Centre;
Blackpool Teaching Hospitals NHS Foundation Trust;
Lancashire and South Cumbria NHS Foundation Trust;
North West Ambulance Service. | On 5 September 2019 an investigation was commenced into the death of Marlene McCabe. An inquest was opened on 10 September 2019. The investigation concluded at the end of the inquest held at Blackpool Town Hall on 6 March 2023 � 23 March 2023 and 3 May 2023. Conclusion of Investigation (Section 4) Unlawful killing. On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant�s undiagnosed and untreated schizophrenia coupled with alcohol intoxication. �
Cause of death: 1 (a) Severe blunt force head and facial injuries. | Box 3 of the Record of Inquest recorded as follows: On 4th September 2019, between around 5.10pm and 5.50pm, Marlene McCabe was killed unlawfully in her own home. She died as a consequence of being struck a multiplicity of times to the head and face with a blunt object, namely, a doorstop, which occasioned catastrophic head and facial injuries. The actions of her assailant were more than minimally contributed to by the assailant�s undiagnosed and untreated schizophrenia coupled with alcohol intoxication. There were accepted prior failures in the collation and consideration of information, including from the available records and family, and in the mental health assessment of and progression of treatment for the assailant, in particular from early July 2019, which did not more than minimally contribute to Marlene McCabe�s death. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
(i)���� The family of Marlene McCabe
(ii)����[REDACTED], Bloomfield Medical Centre
(iii) Chief Constable of Lancashire Constabulary
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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: Bloomfield Medical Centre,� Blackpool Teaching Hospitals NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust and North West Ambulance Service. | |
12/05/2023 | 2023-0153 | Barbara Mitchell | North London | Bluebird Care (Brent)
107 Kenton Road
Harrow
Middlesex HA3 0AN | On the 13th July 2022 I opened an investigation touching the death of Barbara Mitchell ,
aged 94 years old. I opened and heard an inquest on the 7th December 2022. The
conclusion of the inquest was � Barbara Mitchell died as the result of an accident �, the
medical case of death was 1a Pneumonia, 1b Fracture of Sternum and under paragraph
2 Atrial Fibrillation. | On the 9th July 2022 Barbara Mitchell died at Northwick Park Hospital having fallen at home despite being assisted at the time by a carer. | I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons;
The Family
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest. You may make representations to me, the coroner, at the time of your
response, about the release or the publication of your response by the Chief Coroner | Care Home Health related deaths
This report is being sent to: Bluebird Care (Kent) | |
11/7/2024 | 2024-0370 | Peter Dolan | Cheshire�
�
Category: Other related deaths�
�
This report is being sent to: Boat Safety Scheme | Boat Safety Scheme Boat Safety Scheme | On 09 April 2024 I commenced an investigation into the death of Peter Richard DOLAN aged 63. The investigation concluded at the end of the inquest on 09 July 2024. The conclusion of the inquest was that:
Accident | On 08/03/24 a fire took place on a canal boat on the Bridgewater Canal, Whitbarrow Road
in Lymm. When the fire was extinguished a badly burnt body was recovered from inside the canal boat which was later identified as being Mr Dolan. Police attended and confirmed that there was no suspicious circumstances.
Reason for inquest � unnatural 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] Cheshire Fire & Rescue 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. | Other related deaths�
�
| |
13/12/2022
| 2022-0414 | Akeem Rhoden | South Wales Central
| Brecon Beacons National Park Authority;
Rhondda Cynon Taff CBC;
Neath Port Talbot Council;
Powys County Council; and
Natural Resources Wales | On 15 June 2021 I commenced an investigation into the death of Akeem Jevaughn RHODEN .
The investigation concluded at the end of the inquest on 29th November 2022.
The conclusion of the inquest was misadventure.
The cause of death was recorded as:
1a Drowning | Akeem Jevaughn Rhoden was aged 22 when he voluntarily jumped off a rock into the water at Sgwd Y Pannwr Waterfall, Brecon Beacons, near Pontneddfechan on 5th June 2021. He was not a strong swimmer and he drowned due to the force of the water. His body was recovered on 6th June 2021, having been trapped under a ledge. | I have sent a copy of my report to Mr Rhoden�s family who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Other related deaths | Wales prevention of future deaths reports (2019 onwards)
| Brecon Beacons National Park Authority, Natural Resources Wales, Neath Port Talbot Council, Powys County Council and Rhondda Cynon Taf County Borough Council |
08/12/2017 | 2024-0092 | Paul Gander | West Sussex, Brighton and Hove | Brighton and Sussex University NHS Hospital Trust | On Fifteenth June 2017 I commenced an investigation into the death of Paul Eric GANDER. The investigation concluded at the end of the inquest on Twenty seventh November 2017.
The conclusion of the inquest was a NARRATIVE CONCLUSION. | See Record of Inquest | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
1. [REDACTED]
[REDACTED], Solicitor
Secretary of State for Health, Department of Health
[REDACTED], Chief Executive, NHS England
Care Quality Commission
Clinical Commissioning Group
�
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief
Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Brighton and Sussex University NHS Hospital Trust | |
05/08/2024 | 2024-0562 | Janet Harrison | Hampshire, Southampton and Portsmouth | Building Control Inspector, Eastleigh Borough Council
Building Control Inspector, Southampton City Council (as building control services are offered in partnership with Eastleigh Borough Council) | On 6 September 2022 I commenced an investigation into the death of Janet Karen HARRISON aged 76. The investigation concluded at the end of the inquest on1 July 2024. Janet Karen HARRISON died on 31 August 2022 in hospital from pneumonia following the collapse of her neighbour�s wall on 18 February 2022 for which she suffered from polytrauma.� The medical cause of death was confirmed as 1a. hospital acquired pneumonia, 1b. infected left gluteal haematoma, frailty, 1c. polytrauma and 2. hypertension, DVT and cholecystitis. The short-form conclusion reached was accident. | On 18 February 2022, the UK was affected by Storm Eunice for which the Met Office had issued two severe weather warnings. In the area where Janet Karen HARRISON lived, the weather was reported to be wet and windy with gusts of around 50 to 60mph.� At approximately 12.10pm on 18 February 2022, Janet Karen HARRISON was found in her garden under her neighbour�s collapsed wall by her neighbour.� As a result of the accident, she suffered from life threatening and catastrophic injuries including multiple fractures.
�
Two admissions at Southampton General Hospital followed from 18 February 2022 to 31 March 2022 and from 14 April 2022 until her death on 31 August 2022 and a short admission to Romsey Rehabilitation hospital during the intervening period from 31 March 2022 to 14 April 2022 when Janet Karen HARRISON was deemed to be medically optimised.� During her first admission in the hospital she acquired deep vein thrombosis and hospital acquired pneumonia for which she was treated. In her second admission to Southampton General Hospital, she suffered from a bacterial infection and a gastrointestinal bleed for which she was treated. She continued to show signs of an infection in June and July 2022 and was treated for cholecystitis.�She also suffered from left gluteal haematoma for which she was treated surgically on 8 August 2022 and 27 August 2022 due to ongoing concerns of infection.� She died on 31 August 2022 from hospital acquired pneumonia.
The Court heard evidence from [REDACTED], Head of the Structural team at Hampshire County Council who gave evidence that the wall was unsafe and should never have been built to a height of 1.95 metres given that it was a half brick wall.� The impact of the storm was worsened by the fact that a large surface area of fencing panel was attached to the wall which meant that it was susceptible to collapsing as the fencing panel acted as a sail when exposed to the winds from Storm Eunice thereby contributing to the wall coming down. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons the Family of Janet Karen HARRISON.� I have also sent it to [REDACTED] who may find it useful or of interest.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Other related deaths | Eastleigh Borough Council | Southampton City Council |
07/06/2023 | 2023-0191 | Brenda Shields | Cumbria | CEO Cumbria, Northumberland, Tyne and Wear NHS Trust | On 15 December 2022 I commenced an investigation into the death of Brenda SHIELDS age
The investigation concluded at the end of the inquest on 6th June 2023 . The conclusion of the inquest was:
Death from self-suspension while her cognition was seriously impaired by a very high blood alcohol level.
3 1a Hanging
1b
1c
II Alcohol dependence | The record of inquest read as follows: �Brenda Shields died in her home , [REDACTED], Carlisle on 8th December 2022. She took her life by ligature suspension while under the influence of a very high blood alcohol level�. A narrative conclusion was given.
Brenda worked as a healthcare assistant in A&E at Cumberland Infirmary, she had for some time been alcohol dependent with binge sessions which often caused domestic friction with her husband, there was an incident of domestic violence requiring police involvement. Matters had been worse since she developed cauda Equina Syndrome which required neurosurgical intervention in 2021, and had ongoing low back pain which she tended to medicate with alcohol. She had had episodes of anxiety in 2005 & 2007, depression on 2016 & suicidal ideation in 2018. On 26/10/22 she was admitted to A&E in Carlisle (her own workplace) with an intentional overdose. She was followed up and treated by her GP. On 10/11/21 there was a serious incident when she was found by police on the riverbank, she had intended to enter the water but was talked down from this by her GP. Brenda was admitted to hospital [Hadrian unit] as a voluntary patient.
Brenda was not comfortable in the ward environment and on 14/11/21 discharged home to be followed up by the Crisis Team who did visit her at home the following day. Brenda�s GP was not informed of her admission or discharge so was unaware of events until a prearranged telephone call on the 15th. Brenda was followed up at home and by telephone, at several contacts she was noted to be under the influence of alcohol. Brenda was discharged after a final �MDT� meeting on 6/12/22 [it is not clear who was involved], declining further input and denying any thoughts of self harm, a risk assessment on 8/12/22 records low or no apparent risks, this was the day Brenda died. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : Brenda�s family and her GP [REDACTED] of Eden Medical Group, Carlisle
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015) | Alcohol, drugs medication related deaths
This report is being sent to: Northumberland, Tyne and Wear NHS Trust | |
05/03/2024 | 2024-0298 | Isabella Shere | London Inner (South) | CEO of Quora,
[REDACTED]The Rt Hon Lucy Fraser KC MP,
The Secretary of State for Culture, Media and Sport
OFCOM | On 9 February 2023 an investigation commenced into the death of Isabella Shere, aged 14 years old. The investigation concluded at the end of the inquest on 20 February 2024. The conclusion of the inquest was suicide.
The medical cause of death was 1a Asphyxia caused by 1b Hanging. | Miss Shere died on 2 February 2023 at her home address in Lewisham, London. [REDACTED]. Her family left the house at around 8 am. Miss Shere was found at 1:21pm and her phone showed a timer which was running at 5 hours and 13 minutes. [REDACTED]. Miss Shere was not known to have been struggling with her mental health but her internet search history in the last four months of her life indicated that she was seeking information relating to methods of ending life. Miss Shere left a note indicating an intention to take her own life. | I have sent a copy of my report to the Chief Coroner and to Miss Shere�s parents who are Interested Persons and to the Local Safeguarding Board.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015) | Child Death (from 2015)
This report is being sent to: Quora | Department for Culture, Media and Sport | OFCOM | |
20/12/2023 | 2024-0005 | Ryan Evans | Hampshire, Portsmouth and Southampton | CEO, Frimley Health NHS Foundation Trust (FPH)
CEO, Surrey and Borders Partnership NHS Foundation Trust (SABP) | On 4th April 2018 I commenced an investigation into the death of Ryan John EVANS. The investigation concluded at the end of the inquest on 23rd January 2023. The inquest was heard with a Jury. �
Mr. EVANS died of:
1a:���� Asphyxia
1b:���� Suspension by the neck �
The jury returned the following narrative conclusion: �
Narrative conclusion
Ryan John Glyn EVANS was a 20 year old man with a global learning delay (a learning disability) and was registered disabled. He had a diagnosis of depression which dates back to 2016. He was physically fit and was living on his own in assisted living with seven hours of support a week. �
Ryan was adopted at age two along with his older brother and sister and were brought up in a close family unit with his adoptive parents, following a traumatic early childhood. �
Ryan was vulnerable due to his learning disability and depression, recent self- harm and attempts of suicide. �
Ryan�s mental health had deteriorated over approximately seven months due to a number of contributory factors.
Notice to leave his accommodation and uncertainty of future living plans.
Finding out the nature of his biological fathers suicide (hanging) via social media
Medication, drugs and alcohol
Breakdown in relationship with ACASA management
Ryan was arrested on 2nd April outside ACASA offices for:
-Outstanding criminal damage
-Threatening behaviour
-Violent / Abusive phone calls
�
Ryan was taken to Frimley Park Hospital by ambulance following collapse in the police van with chest and abdomen pain, his self-harm injuries were dressed and no physical issues were discovered so he was released into police custody. Despite evidence of self-harm, no Mental Health Assessment was carried out at this point.
�
On booking into police custody, Ryan was noticeably upset. He was referred to and visited by a Health Care Professional (HCP) and Hampshire Liaison and Diversion Service (HLDS) at the request of the police custody sergeant.
�
-HCP reviewed his physical condition and redressed his self-harm injury
-HLDS failed to document the encounter on the RIO system and only updated the custody record with a screening document.
�
This follows a failure to update the RIO system in January 2018 when Ryan was previously seen by HLDS.
�
There was failure to carry out a Mental Health Assessment and no record of Ryan refusing to be assessed. It could not be concluded that these shortcomings significantly shortened Ryan John Glyn EVANS life.
�
HLDS report screen was completed and uploaded onto the custody record with no reference to a Mental Health Assessment being required or declined by Ryan.
�
Throughout Ryan�s stay in custody he expressed suicidal ideations on multiple occasions, spoke to the Samaritans and concerns were raised by family which were reported back to the custody Sergeant. Communication of this information was ineffective. Additionally, across the custody suite there was a sense of complacency with references to Ryan�s behaviour being �attention seeking� and no future referrals to HLDS were made. Despite no formal guidance, it is regrettable that on disposal, no verbal handover was done with Ryan�s father. It could not be concluded that these shortcomings significantly shortened Ryan John Glyn EVANS life.
�
Ryan was released into the care of his father at approximately 22:30 from Basingstoke Custody Centre. He was in a distressed state over the conditions of his discharge and how he found out about his biological father committing suicide by hanging.
�
Ryan refused to go home to his parents residence and wanted to go to his own accommodation. His father dropped him off around midnight and waited till Ryan was safely in the building.
�
Ryan was found hanging the following morning, 3rd April 2018, by a fellow resident in the communal area of the building.
�
Ryan had a long standing history of depression and several suicide attempts.
Ryan John Glyn EVANS took his own life while suffering from the diagnosed medical illness of depression. | The circumstances of the death are recorded in the Jury�s Narrative Conclusion. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely:
�
Family of Ryan John Glynn EVANS Hampshire Constabulary
[REDACTED], Hampshire Constabulary
[REDACTED], �Hampshire Constabulary Southern Health NHS Foundation Trust
[REDACTED], Former SHFT Employee, Registered Mental Health Nurse
MITIE
[REDACTED], �Former MITIE Employee, Health Care Practitioner (HCP) Alexander�s Care and Support Agency (ACASA)
IOPC
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
This report is being sent to: Frimley Health NHS Foundation Trust | Surrey and Borders Partnership NHS Foundation Trust | |
20/06/2024 | 2024-0332 | Shelemiah Peterkin | Birmingham and Solihull | CHIEF EXECUTIVE OF BIRMINGHAM AND SOLIHULL MENTAL HEALTH FOUNDATION TRUST | On 8 February 2024 I commenced an investigation into the death of Shelemiah Pedaiah�PETERKIN. The investigation concluded at the end of the inquest. The conclusion of the inquest was: Suicide | On 02/10/2023, Shelley was reported missing by a friend. Following concerns for Shelley�s�welfare, police forced entry to her home at 23:45 where she was sadly found deceased, and�she had clearly been deceased for some time. Post mortem and toxicological analysis�confirmed that she died as a result of intentional consumption of [REDACTED] which she had purchased off the internet. Shelley had been spoken to by police on 03/09/2023 about the reasons for the purchase and she had reassured them as to its use. She had a history of poor mental health and was under the care of the community mental health team at the time of her death. Shelley had missed her planned monthly depot injection on 18/09/23 and the mental health team were trying to locate her. There was a missed opportunity by the police to force entry to her home on 27/09/2023, but it is not possible to say whether she would have been found alive at that time.� �
Following a post mortem, the medical cause of death was determined to be:�
1a� [REDACTED] poisoning | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:�
�[REDACTED] (Next of Kin)�
�I have also sent it to the ICS and NHS England who may find it useful or of interest.� �I am also under a duty to send the Chief Coroner a copy of your response.� �The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may� make representations to me, the coroner, at the time of your response, about the release or the� publication of your response by the Chief Coroner. | Suicide (from 2015) | Mental Health related deaths
This report is being sent to: Birmingham and Solihull Mental Health Foundation Trust | |
19/07/2023 | 2023-0267 | Shane West | Swansea Neath Port Talbot | CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR | On the 20th August 2018 I commenced an investigation into the death of Shane Luke West. The investigation concluded at the end of the inquest on the 19th July 2023. � The medical cause of death is 1a) multi organ failure 1b) carfdio respiratory arrest 1c) abdominal distention caused by faecal impaction 2 sotos syndrome, scoliosis �
The conclusion of the inquest as to how Mr West came to his death was a narrative conclusion and is as follows:
The deceased died from multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention. The distension was caused by longstanding chronic constipation and fluid build up from his laxative treatment. | The deceased was Shane Luke West and he was pronounced dead on the 17�h August 2018 at Morriston Hospital, Swansea. The cause of death was multi organ failure caused by cardio respiratory arrest due to increased pressure on the lungs from abdominal distention, which itself was caused by longstanding chronic constipation and fluid build up from his laxative treatment. �
Shane was admitted to Morriston Hospital on the 31st of Julv 2018 with chronic constipation and abdominal swelling. The treatment plan was conservative consisting of laxatives, enemas and colonic irrigation. Shane also had SOTOS syndrome and suffered from a learning disability. The learning disabilities team of the Health Board were involved to allow Shane to understand the treatment being offered. It was noted that the extent of the constipation on admission was causing significant abdominal distention the result of which meant that Shane�s abdomen was pushing his diaphragm up into the chest cavity thereby restricting his lung function. Shane underwent regular examinations with varying results. On some occasions his abdomen felt distended, and on others it felt soft and non tender, suggesting improvement. On the 16th of August 2018 Shane deteriorated with respiratory compromise. Shane underwent a colectomy and ileostomy formation to decompress the abdomen to allow effective mechanical ventilation. Whilst this procedure provided temporary improvement, Shane eventually declined further and passed away on the 17?� of August 2018. | I have sent 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. | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Swansea Bay University Health Board | |
04/03/2024 | 2024-0121 | Jean Thomas | Swansea Neath and Port Talbot | CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR �
CHIEF EXECUTIVE WELSH AMBULANCE SERVICE NHS TRUST BEACON HOUSE WILLIAM BROWN CLOSE CWMBRAN NP44 3AB | On the 20th February 2023 I commenced an investigation into the death of Jean Thomas. The investigation concluded at the end of the inquest on the 29th February 2024. �
The medical cause of death is 1a Infected Sacral pressure sore associated with long lie and reduced mobility
1b)
1c)
2 Frailty of old age, previous stroke, fractured neck of femur (operated 16.12.22) �
The conclusion of the inquest as to how Mrs Thomas came to her death was a narrative conclusion and is as follows: �
The deceased died of an infected pressure sore caused by a long lie whilst waiting for an ambulance following a fall at home and exacerbated by a delay in handing the deceased over to the Emergency Department and sourcing an anti-pressure sore mattress. | The deceased was Jean Thomas who was pronounced dead on the 10th of February 2023 at Morriston Hospital, Swansea. The cause of death was an infected sacral pressure sore associated with long lie and reduced mobility. �
Jean was admitted to Morriston Hospital on the 14th of December 2022 after having suffered a fall at home on the 13th of December 2022. The fall occurred at approximately 12:30pm on the 13th December 2022 and the ambulance arrived at 2:48am on the 14th December 2022, meaning that Jean had been on the floor for 14 hours during which time a pressure sore had begun to develop. Jean was taken to hospital but remained in the ambulance until 20:56.
�
Jean suffered a fracture to the neck of her femur as a result of the fall and this was operated and repaired on the 16th of December 2022. Despite a pressure sore having begun to develop by the time of admission to hospital on the 14th of December, no airflow mattress was obtained until the 20th of December. Jean underwent treatment for the pressure sore as well as antibiotics to prevent infection. Whilst the pressure sore showed signs of improvement with treatment, the wound then deteriorated due to a failure in the seal of the vacumn dressing, resulting in the wound being contaminated. This contamination resulted in the pressure sore becoming infected and Jean passed away on the above date. | 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. | Emergency services related deaths (2019 onwards) |
Wales prevention of future deaths reports (2019 onwards)
This report is being sent to: Swansea Bay University Health Board | Welsh Ambulance Service | |
24/04/2024 | 2024-0224 | Nicholas Harrison | Swansea Neath and Port Talbot | CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY BAGLAN ENERGY PARK BAGLAN PORT TALBOT SA12 7BR �
[REDACTED] DIRCTOR GENERAL OF HEALTH AND SOCIAL SERVICES / CHIEF EXECUTIVE OF NHS WALES TY DYSGU, NANTGARW, CF15 7QQ. �
[REDACTED} CHIEF EXECUTIVE OF THE CITY AND COUNTY OF SWANSEA | On 12 April 2022 an investigation was commenced into the death of Nicholas Kim Harrison. The investigation concluded at the end of the inquest on 16 April 2024. �
The medical cause of death was: 1a Hypoxic-Ischaemic Brain Injury 1b Traumatic Brain Injury �
The conclusion of the inquest was a narrative conclusion as follows: �
On 12 March 2022 Kim Harrison was seriously assaulted by his son the perpetrator at the family home. As a result of this assault Kim sustained significant head and face injuries which caused his death on 9 April 2022. At the time of the assault, the perpetrator had absconded from Ward F of Neath and Port Talbot hospital where he was subject to detention powers under section 2 of the Mental Health Act 1983 following an informal admission on 2 March 2022. The perpetrator had been detained as doctors considered that he posed a potential risk of violence to others. At the time of the assault the perpetrator was suffering from untreated schizophrenia which caused him to have paranoid delusions about his father.
�
The perpetrator had been receiving care and treatment from Swansea Bay University Health Board (�SBUHB�) for his mental ill health from 2007 onwards which included taking the drug Olanzapine. In 2009 the perpetrator was wrongly removed from the care of Area 3 Community Mental Health Team. This contributed to a lack of continuity in care for the perpetrator in 2018 when his treating consultant left. At this point SBUHB failed to put in place appropriate and timely follow-up arrangements from a replacement consultant psychiatrist which caused the perpetrator to become disengaged from services when he was vulnerable. This caused the perpetrator to wean himself off Olanzapine in an unmanaged and unmonitored way. This led to a return of the perpetrator�s psychotic symptoms and a deterioration in the perpetrator�s mental health to the point where the perpetrator lost insight into his condition and his risk to himself, and others, began to increase. The perpetrator probably would have engaged with a suitable replacement consultant psychiatrist had one been offered by SBUHB in a timely manner in 2018 such that his mental health would not have deteriorated in the way that it did. There was a failure by SBUHB to put in place appropriate and timely follow up arrangements from a consultant psychiatrist for the perpetrator in 2018 and this contributed to Kim�s death.
�
From June 2020 to March 2022 The perpetrator�s parents [REDACTED] and Kim Harrison consistently raised with SBUHB and the City and County of Swansea AMPH service concerns about the perpetrator�s deteriorating mental health in their attempts to get help for the perpetrator. The perpetrator did not want to engage with mental health services, and he did not want information to be shared with his parents as he had lost insight into his mental ill health. SBUHB clinicians and the City and Country of Swansea AMPH service did not pay sufficient attention to the collateral information being provided about the perpetrator by his family. From July 2020 onwards SBUHB clinicians, including the Community Mental Health Team, should have ensured that the perpetrator was regularly and assertively visited in the community so that the perpetrator could be re-engaged with mental health services.
�
The perpetrator was subject to a Mental Health Act Assessment on 27 April 2021 and not admitted to hospital for assessment. This assessment was flawed as there was a failure by SBUHB to gather all available collateral information to inform the assessment, a failure to have due regard to the collateral information during the assessment and inadequate consideration of the risks the perpetrator posed to himself and others. The assessment was also not informed by a detailed understanding of the perpetrator which would have occurred had SBUHB assertively engaged the perpetrator in the community from June 2020 onwards.
�
I find that these failures possibly contributed to Kim�s death.
�
The perpetrator was admitted to Ward F on 2 March 2022 after behaving in a psychotic manner in the family home and being verbally aggressive and confrontational towards his parents. SBUHB accept that when the perpetrator was on Ward F his risk assessments were not fully completed. SBUHB also accept that the perpetrator had not been subject to an adequate multi-disciplinary team assessment and that the perpetrator�s family members� views and concerns had not been fully recorded and therefore could not be taken into account and recorded on the risk assessments and that there was no clear plan in place regarding the perpetrator�s non-
concordance with medication. There was no documented assessment of the risk of the perpetrator absconding but if it had been assessed it would have been classified as a low risk. These matters did not contribute to Kim�s death.
�
On 12 March 2022 the perpetrator absconded through the front door of Ward F when it was being held open by a member of staff who was talking through the door. The security systems in place at the time in Ward F were not fit for purpose. This is because the infrastructure and design in relation to door access was unsafe and in turn was being operated in an unsafe manner due to a lack of adequate training of staff by SBUHB. This was at a time when Ward F was known to be under significant pressure. Further, this defective system was not picked up or identified through regulatory oversight by SBUHB because they had not conducted a review of the security of Ward F despite a significant increase in the rate of absconding.
�
This system failure (defect in the security system and inadequate training of staff on door security in Ward F) contributed to Kim�s death. | The deceased was Nicholas Kim Harrison (�Kim�). On 12 March 2022 Kim was seriously assaulted by his son [REDACTED] at the family home. As a result of this assault Kim sustained significant head and face injuries associated with a traumatic brain injury and significant neck injuries and rib fractures. Kim received intensive medical care. During this time Kim remained neurologically impaired and then died.� At the time of the assault on his father, [REDACTED] had absconded from Ward F of Neath and Port Talbot hospital where he was subject to detention powers under section 2 of the Mental Health Act 1983 (�MHA 83�). [REDACTED] had been detained as he was considered to be a risk to others. At the time of the assault [REDACTED] was suffering from untreated schizophrenia which caused him to have paranoid delusions about his father, Kim. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons, Swansea Bay University Health Board, City and County of Swansea, South Wales Police, 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. | Other related deaths | Mental Health related deaths | Wales prevention of future deaths reports (2019 onwards)
This report is being sent to: Swansea Bay University Health Board | NHS Wales | City and County of Swansea | |
22/10/2024 | 2024-0565 | Peter Parker | SWANSEA NEATH & PORT TALBOT | CHIEF EXECUTIVE SWANSEA BAY UNIVERSITY HEALTH BOARD 1 TALBOT GATEWAY��
BAGLAN ENERGY PARK��
BAGLAN�
PORT TALBOT��
SA12 7BR�
CHIEF EXECUTIVE WELSH AMBULANCE SERVICE NHS TRUST BEACON HOUSE�
WILLIAM BROWN CLOSE�
CWMBRAN�
NP44 3AB�
[REDACTED], DIRECTOR GENERAL FOR HEALTH AND SOCIAL SERVICES WELSH ASSEMBLY GOVERNMENT�
CATHAYS PARK�
CARDIFF�
CF10 3NQ | On the 20th September 2021 I commenced an investigation into the death of Peter�Parker. The investigation concluded at the end of the inquest on the 16th October 2024.
The medical cause of death is:
1a) haemorrhage from sharp force injury to right wrist including transection of right radial artery.�
1b)������� �
1c)������� �
2�
The conclusion of the inquest as to how Mr Parker came to her death was a narrative conclusion and is as follows:-�
The deceased died of a haemorrhage from a transected radial artery caused by broken glass at home, contributed to by the significant delay in the arrival of the requested�ambulance. | The deceased was Peter Parker who was pronounced dead on the 11th of September� 2021 at his home address of [REDACTED]. The cause of death was a haemorrhage from sharp force injury to right wrist including transection of right radial�artery.
Peter sustained a laceration injury to his right wrist whilst at home after falling and�cutting himself on broken glass. Peter dialled 999 for an ambulance at 9:19pm on the�10th of September 2021 and stated that he had cut a vein and blood was pumping out.� Approximately 3 � minutes into the call, the line disconnected at the time when the call� handler was attempting to give Peter advice on how to suppress the bleeding. The call- handler for The Welsh Ambulance Service Trust (WAST) made five attempts to� reconnect the call and make welfare checks without success. The MPDS system in�operation by WAST gave the call an Amber 1 priority meaning that the call would be�dealt with in order of receipt after all the Red priority calls were cleared. The requested� rapid response vehicle arrived at Peter�s home at 6:30am on the 11th of September 2021 and with the assistance of Police access was gained to Peter�s home at 7:00am. This� was approximately 9 � hours after the ambulance was requested. Peter was�pronounced deceased at the scene at 7:09am. | 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. She may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your�response, about the release or the publication of your response by the Chief Coroner. | Emergency services related deaths (2019 onwards)�| Wales prevention of future deaths reports (2019 onwards) | Other related deaths | SWANSEA BAY UNIVERSITY HEALTH BOARD | WELSH AMBULANCE SERVICE NHS TRUST | WELSH ASSEMBLY GOVERNMENT |
27/01/2023
| 2023-0063 | Andrew Shirley | Worcestershire
| CORONER
I am David Donald William Reid, HM Senior Coroner for the coroner area of Worcestershire | CIRCUMSTANCES OF THE DEATHS
In answering the questions �when, where, how and in what circumstances did Andrew come by his death, the jury found as follows:
�On 23.3.21 Mr. Andrew Shirley was found unresponsive in cell 14 of the Segregation Unit at HMP Hewall suspended by a ligature. Advanced life saving measures were undertaken but he was pronounced dead at the scene st 1944hrs.�
To clarify, at the time of these events Andrew was a diagnosed paranoid schizophrenic who had been receiving a monthly depot injection of anti-psychotic medication. He also had a documented history of self-harm end suicide attempts. Andrew had been in police custody from 25.2.21 until 1.3.21, during which time he had undergone a formal Mental Health Assessment at the Cauldon Centre, Coventry because of concerns about his mental health. Those conducting that assessment concluded that he did not require treatment in a psychiatric hospital, whether as e detained or voluntary inpatient.
Following a court hearing on 1.3.21, Andrew was remanded Into custody to await trial, end was taken to HMP Hewell.
At the prison, Andrew�s mental health history was noted and he was allocated a mental health care coordinator. During the three weeks that Andrew was at the prison, his care-coordinator failed to carry out any in-depth mental health assessment of him, failed even to begin to formulate a mental health care plan for him, and failed properly to assess and manage his risk of suicide and/or self-harm. The overall failings of the healthcare and mental healthcare teams sit the prison are reflected in the answers of the Jury to Questions 1, 2 and 5 In the Jury Questionnaire (above).
Throughout his time at the prison, Andrew said on several occasions that he felt that his medication was not working.
On 20.3.21 Andrew was placed In the Segregation Unit at the prison, following in incident in which he spat at two prison officers.
In order to assist the Duty Governor In deciding whether Andrew could be held safely on the Segregation Unit, a nurse completed an initial Segregation Health Screen document, in which she recorded that Andrew was currently on anti-psychotic medication. In addition, during the course of her assessment of Andrew, he told her that he was hearing voices which were telling him to kill himself, and that he wanted a radio so that he could drown those voices out. That information was not relayed to the Duty Governor, but the Duty Governor accepted in his evidence that, in light of the information that Andrew was on antipsychotic medication, he should have spoken to, end sought further Information from the nurse.
In their answers to Questions 3 end 4 In the Jury Questionnaire, the July found that, had the Duty Governor sought this further information, he would probably have taken action to reduce Andrew�s risk of suicide and/or self-harm ( e.g. by opening an ACCT document ), and his failure to do so possibly caused or contributed to Andrew�s death on 23.3.21.
Two further Initial Segregation Health Screen documents were completed on 22.3.21, by a paramedic end mental health nurse respectively.
In the first of those the paramedical concerned concluded that there were no �healthcare reasons� not to segregate Andrew at that time. That conclusion was based on two wrong answers in the algorithm contained within that document. The paramedic conceded that she had neither seen Andrew, nor looked at his medical records before completing this document.
The mental health nurse who completed the second Initial Segregation Health Screen document also conceded that he had not seen Andrew beforehand, and accepted in evidence that he might have reached a different conclusion if he had read entries contained within Andrew�s medical notes.
Andrew was found collapsed and unresponsive in his cell on the following evening of 23.3.21, suspended by & ligature. He was confirmed deceased at the scene later that day. | CORONER�S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur until action is taken. In the circumstances It is my statutory duty to report to you.
The MATTERS Of CONCERN are as follows
(1) I heard evidence that v.8 of the ACCT document had been in place at prisons throughout England and Wales since June 2021, and that training relevant thereto consists of:
(I) ACCT v.6 training; and
(II) SASH ( suicide end self-harm) modal 3 training.
However, I also heard that, as at 20.1.23 (over 18 months after the introduction of the latest ACCT document ), 280 out of 400�members of staff at the prison ( 70% ) were yet to have completed that training. It is of considerable concern that such a high percentage of staff at the prison may not be in a position recognise the risk which a prisoner presents of suicide and/or self-harm, and therefore, to take appropriate steps to reduce that risk;
(2) I also heard evidence that, despite the introduction of a new initial. Segregation Health screen algorithm document for prisoners In the Segregation Unit, Duty Governors at the prison had not yet received any training about the steps they should take In order to complete that document appropriately. | D.D.W. Reid H.M.Senior Coroner for Worcestershire 27th January 2023 | State Custody related deaths | Mental Health related deaths
| Various |
09/03/2023
| 2023-0086 | Tomas Ceida | Inner South London
| CORONER �
I am Andrew Harris, Senior Coroner, London Inner South jurisdiction | CIRCUMSTANCES OF THE DEATH �
Construction work was underway on a site being used by the public as a night club. Staff and construction operatives slept overnight on the site on occasions. The jury concluded that the following contributed to the death: Unsuitable composition and state of the acoustic wall Unsafe and inadequately supervised hot works Failure to agree and communicate roles and responsibilities for fire safety on the construction site, leading to inadequate fire alerts and failure to conduct orderly evacuation of the entire site. There were also inadequate fire risk assessments in place, covering Studio 338. | This REPORT IS BEING SENT TO:
1.� [REDACTED], Chief Executive of the Royal Borough of Greenwich, Chief Executive Office, Woolwich Town Hall, Wellington Street, London SE18 6PW
2.[REDACTED], �Commissioner of London Fire Brigade, LFB Headquarters, 169 Union Street, London SE1 0LL
�
3. [REDACTED],�former director, JHS Contracts (JHS), 93b Oak Hill, Walthamstow, Woodford Green IG8 9PF
�
4.�[REDACTED], Chief Executive, Health & Safety Executive, Redgrave Court, Merton Road, Bootle, L20 7HS; Caxton House, Level 7, Tothill Street, London SW1H 9NA | I have sent a copy of my report to the following other interested persons:
� [REDACTED], MPS
� [REDACTED]. JHS Insurers
� [REDACTED], Director of Raduga Ltd
�
I am also copying it to The Fire Protection Association, who may have interest in the matter.
�
I am also under a duty to send the Chief Coroner a copy of your response. He may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Other related deaths
| The Royal Borough of Greenwich | London Fire Brigade | JHS Contracts | Health & Safety Executive |
26/07/2024 | 2024-0408 | Marjorie Michael | Gwent | Cabinet Secretary for Health, Social Care and Welsh Language | INVESTIGATION AND INQUEST
On 25/9/2023, an investigation was opened touching upon the death of Marjorie Joyce Michael
The investigation concluded at the end of the inquest on 17/7/2024
The conclusion of the inquest was recorded as
Narrative Conclusion:
�Marjorie Joyce Michael fell at [REDACTED] residential home in Pontypool on
3/9/2023. Marjorie lay on the floor for over 14 hours waiting for an ambulance. She was eventually conveyed to hospital on 4/9/2023. The long lie resulted in the development of pneumonia and Marjorie died at Nevill Hall Hospital on 6/9/2023. Her death was contributed to by delayed ambulance response�.
The medical cause of death was:
1a) Hypostatic Pneumonia
1b) Fall, Long Lie
1c)
2 Type 2 Diabetes. Ischaemic Heart Disease. | These are described in the Narrative Conclusion in Box 3. | COPIES AND PUBLICATION
I have sent a copy of my report to the Chief Coroner and the following Interested Person (s)
The family of Marjorie Joyce Michael
Chief Executive of Aneurin Bevan University Health board
Chief Executive of Welsh Ambulance Service NHS Trust
�
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Emergency services related deaths (2019 onwards) | Wales prevention of future deaths reports (2019 onwards)�
�
This report is being sent to: Cabinet Secretary Health Social Care & Welsh Language | |
06/11/2023 | 2023-0428 | Madeleine Lawrence
Coroner name: Peter Harrowing
Coroner Area: Avon
Category: Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Care Quality Commission | North Bristol NHS Trust | Care Quality Commission,
[REDACTED] parents of the Deceased
North Bristol NHS Trust
Chief Coroner | On 31st March 2022 I commenced an investigation into the death of Ms. Madeleine Lawrence age 20 years. The investigation concluded at the end of the inquest on 8th September 2023.
The conclusion was that the medical cause of death was
I(a) Multi organ failure;
I(b) Group A Streptococcal sepsis;
I(c) Streptococcal necrotising myositis;
II Traumatic native hip dislocation and the narrative conclusion was �Madeleine Laurence died of a rare complication of an infection which developed after she suffered an injury whilst playing rugby. In hospital her deterioration was not recognised and necessary life-saving treatment was not commenced promptly. Madeleine�s death being contributed to by neglect.� | On 9th March 2022 Ms. Lawrence was playing rugby when she suffered a traumatic native hip dislocation following a tackle. She was taken by ambulance to Southmead Hospital, Bristol where underwent reduction of the dislocation under general anaesthesia. The following day she developed pain in her hip and overnight from 10th to 11th March 2022 her condition deteriorated. Observations were not performed for several hours and when undertaken confirmed her NEWS score of 4. The frequency of the observations were not increased and the provisions of NEWS toolkit and the SEPSIS6 protocol were not followed. The NEWS score later increased to 5 and again observations were not carried in a timely manner and prompt treatment for presumed sepsis was not initiated. �
When Ms. Lawrence was reviewed on Monday 14th March 2022 it was recognised that she was seriously unwell and she was immediately transferred to the Intensive Therapy Unit. She was treated for sepsis and underwent a number of surgical procedures. Ms. Lawrence was diagnosed with necrotising myositis but despite all efforts her condition deteriorated and she died in hospital on 25th March 2022. �
During the course of my investigation I became aware that the NHS Trust had taken steps to increase awareness and training in the NEWS toolkit and the recognition and treatment of the deteriorating patient and sepsis in particular. The focus of the Trust�s efforts had been the ward where Ms. Lawrence was accommodated but that training across the wider Trust was ongoing. | I have sent a copy of my report to [REDACTED], parents of the deceased,North Bristol NHS Trust, and the Care Quality Commission.
�
I shall send a copy of your response to [REDACTED] and North Bristol NHS Trust
�
I have sent a copy of my report to the Chief Coroner.
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | |||
02/02/2024 | 2024-0052 | Susan Bracegirdle | Manchester South | Care Quality Commission, Chief Executive of the One Stockport Integrated Care Board | On 10th February 2023 I commenced an investigation into the death of Susan Wendy BRACEGIRDLE. The investigation concluded on the 3rd July 2023 and the conclusion was one of Narrative: Died from osteomyelitis where the deterioration of the sacral pressure ulcer was not recognised until she became very unwell and attempts to treat it were unsuccessful.
The medical cause of death was:
1a Osteomyelitis secondary to infected sacral pressure sore;
II Vascular Dementia | Susan Wendy Bracegirdle had limited mobility and was at high risk of developing pressure ulcers. She resided in a care home. The District Nursing team were responsible for management of the pressure ulcer that she developed. In October 2022 the pressure ulcer became a stage 3 pressure ulcer. The District Nursing team continued to manage it with support from the Tissue Viability team. On 9th December the wound showed signs of exudate and smelt. On 11th December 2022, Mrs Bracegirdle was hot to the touch when seen by the district nurses. A remote GP review prescribed a cream. No observations were taken. On 13th December 2022 care staff escalated Susan Bracegirdle to the GP. She was referred to the community intravenous team for antibiotics and on 14th December to a nursing bed in the home. On 16th December 2022 Mrs Bracegirdle was taken to Stepping Hill Hospital as she was deteriorating further. On admission she was very unwell. She was treated for sepsis. She became frailer and her physiological reserves were significantly reduced. A MRI scan confirmed Osteomyelitis. Despite continuing treatment with antibiotics Mrs Bracegirdle continued to deteriorate and died at Stepping Hill Hospital on 9th February 2023. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely [REDACTED], on behalf of Ms Bracegirdle�s family, and Stable Steps Care Centre, 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: Care Quality Commission | |
14/10/2024 | 2024-0556 | Sally Mills | Berkshire | Caremark (Chiltern & Tree Rivers)
5 Greenway, Chesham HP5 2DA | On 28 July 2023 an investigation commenced into the death of Sally Mills, aged 85. The investigation concluded at the end of the inquest on 11 October 2024. The conclusion of the inquest was that Sally Mills died as a result of choking on her prescribed medication, which was contributed to by continued administration of medication following signs of difficulties in swallowing against a background of recent difficulties. A forensic post- mortem examination concluded her medical cause of death was consistent with choking. | The deceased received carers 4 times a day at her home address, and they assisted her in the administration of her medication. She took 5 tablets in the morning. Following concerns raised by the District Nurse on 18 July 2023, regarding swallowing of tablets, care� assistants� were� advised� to� keep� the� deceased� at� a� 90-degree� angle� when administering medication. This was implemented into her care plan. On 22 July 2023 further� difficulties� with� taking� the� medication� were� noted� twice� that� day� and� not escalated.
On 23 July 2023 the deceased�s medication was administered with the assistance of a care assistant at home. She was displaying signs of discomfort following the 3rd tablet and then difficulty swallowing the 4th tablet. She choked after taking the 5th tablet becoming unresponsive. Paramedics attended and she was conveyed to Wexham Park Hospital where she passed away the same day at 9.30am. | I have sent a copy of my report to the Chief Coroner and to the family of Sally Mills.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 | Caremark (Chiltern & Tree Rivers) |
13/11/2023 | 2023-0447 | John Pace | Essex | Castle Rock Group Forward Trust | On 30 July 2020 I commenced an investigation into the death of Mr John Paul Pace. The investigation concluded at the end of the inquest on 25 October 2023. � The conclusion of the inquest was a short form conclusion of �Drug Related Death�. On 29 November 2019, Mr John-Paul Pace was recalled to prison after being arrested for a drug related offence. He was sent to HMP Chelmsford. When he arrived at Chelmsford, Mr Pace tested positive for both opioids and [REDACTED]. He was put on a drug detoxification programme and was prescribed methadone (an opiate substitute), which was progressively reduced over the following months. He was under the care of the GP to manage his depression and of the Integrated Drug Treatment Services to manage his drug use. On 28 May 2020, Mr Pace stopped taking methadone, before he had completed the methadone reduction programme. He was prescribed medication to help with the expected withdrawal symptoms. Shortly after 8.00am on 22 July 2020 Mr Pace was found unresponsive. An ambulance attended the prison and Mr Pace was certified dead at 8.16am. | ������� Mr Pace was serving a prison sentence at HMP Chelmsford for a drug related offence;
������� Mr Pace was under the care of the Integrated Drug Treatment Service delivered by Forward Trust and was following a methadone detoxification programme;
������� Mr Pace decided to stop methadone against medical advice before completing the detoxification programme;
The post mortem examination concluded Mr Pace�s likely medical cause of death was �synthetic cannabinoid misuse�. The synthetic cannabinoid in question is known as �[REDACTED]�. | I have sent a copy of my report to the following.
�
?����� Mr Pace�s family
?����� The Care Quality Commission
?����� The MOJ (and HMP Chelmsford)
�
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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
This report is being sent to: Castle Rock Group | Forward Trust | |
13/07/2023 | 2023-0431 | Mackenzie Cooper | Nottingham City and Nottinghamshire | Central England Co-operative (Food)The Department for Health and Social Care | On 17 October 2022 I commenced an investigation into the death of Mackenzie COOPER, aged 27. The investigation concluded at the end of the inquest which took place before a jury on 12 July 2023. The conclusion of the jury was that: � Mackenzie Cooper died on 29 September 2022 at a private residential dwelling in [REDACTED] , Nottinghamshire, as a result of cardiac arrhythmia induced by electrocution. � Mackenzie was a Plumber, qualified to NVQ level 2 and 3 in Domestic Plumbing and Heating, and Gas Safe Registered, with 5 years� experience working independently. �
He was called out to a residential property to deal with an emergency leak, and he attended alone. The electricity was turned off before Mackenzie arrived. The power was turned on to enable Mackenzie to vacuum up water. He was electrocuted when kneeling in water, he touched or came into close proximity to a copper pipe that was inadvertently carrying a live electrical current when the power was switched on. This was due to a combination of two faults in the house electrical system: �
The earth terminal in the fuse box was not connected to general mass of earth;Faults or inadvertent connection between live and earth in the main socket circuit. � Both of these faults in combination caused the pipe to carry a live electrical current, once the power was switched on. �
The occupier called 999, and commenced CPR, continuing until ambulance crews arrived. The homeowner fetched a community public access defibrillator, which was not functional due to missing pads. An ambulance arrived after 20 minutes, a short delay resulting from resource availability, but there was no evidence these factors contributed to his death as he was already asystole when ambulance crews arrived. �
Mackenzie was pronounced deceased at the scene at 15.43. | (relevant to this report)
The occupier of the private dwelling gave evidence that he and his wife were advised by the East Midlands Ambulance Service NHS Trust, during the course of the 999 call, to fetch a nearby community public access defibrillator from the Co-op store, 29 Doncaster Road, Carlton-in-Lindrick, Worksop, Nottinghamshire, S81 9JX.
�
The device was provided to the occupier by co-op staff. When the occupier arrived at Mackenzie�s side and opened the defibrillator pack, the audible instructions advised that the pads should be connected to the leads. On exploring the entirety of the device pack, it became apparent there were no pads, meaning the device could not be used. This delayed the use of a defibrillator, and the administration of a shock, if Mackenzie was in a shockable rhythm.
�
When the occupier later returned the device to the Co-op store, staff informed them that they knew the device was missing the pads because they had not been replaced since the device was last used.
�
I received evidence from East Midlands Ambulance Service NHS Trust that responsibility for maintaining the defibrillator device and associated equipment, including replacement pads, rests with the �guardian� of the device, not with the with the ambulance service. The ambulance service simply has access to a list of the locations of community pubic access defibrillators and advise callers of their nearest device in a cardiac arrest scenario.
�
I understand there were other community access defibrillators very close by which the occupier could have accessed if the ambulance service had known the device in the co-op store was �offline�.
�
I understand there is no single database listing the location and status of community public access defibrillators, rather a number of charity organisations provide such a service (NDDb and the British Heart Foundation) and I am unclear how the ambulance service are to know when a listed device is non-functional. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; Mackenzie�s family
His employer
The homeowner and occupier who collected the device in question
�
I have also sent it to
�
The National Defibrillator Database (NDDb) The British Heart Foundation, The Circuit
�
who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Other related deaths
This report is being sent to: Central England Co-operative | The Department of Health and Social Care | |
20/03/2024 | 2024-0155 | Jonathan Harris | Surrey | Chair NHS England PO Box 16738 Redditch B97 9PT | INQUEST �
An inquest into Mr Harris�s death was opened on 21 July 2022. The inquest was resumed and concluded on 4 March 2024. � The medical cause of Mr Harris�s death was: 1a. Suspension 2. Paranoid Schizophrenia The inquest concluded as follows: Suicide.
Jonathan Harris was 52 years old and had a diagnosis of Paranoid Schizophrenia.
On 24 November 2021 he was discharged following a lengthy psychiatric inpatient stay to Hazel Lodge, which provides supported living accommodation in Camberley and is run by Comfort Care Services Ltd. At the time of his discharge from hospital Mr Harris was prescribed anti- psychotic medication in the form of a weekly depot injection of 600mg Zuclopentixol.
Whilst he was living at Hazel Lodge Mr Harris came under the care of his local community mental health team, the Surrey Heath Community Mental Health Recovery Service, which is part of Surrey and Borders Partnership NHS Foundation Trust.
In early February 2022, following a request by Mr Harris, the frequency of his anti-psychotic medication was suitably reduced to 600mg fortnightly as opposed to weekly. Thereafter in early May 2022, following another request by Mr Harris, his anti-psychotic medication was further reduced to 600mg every three weeks. The reduction in his medication in May 2022 was premature and was made without exploring signs that Mr Harris appeared suspicious when he was seen by the mental health team on 4 May 2022 and in circumstances in which Mr Harris was known to have a significant life change ahead, namely a house purchase and move, which would entail him moving to a new community mental health team.
Thereafter, Mr Harris� mental health continued to deteriorate and on 24 June 2022 it was decided by the Community Mental Health Team that he required an assessment under the Mental Health Act. However, there was no inpatient bed available and therefore the assessment did not take place. Had the assessment taken place Mr Harris would have been detained under the Mental Health Act and admitted to hospital.
In the early hours of the morning of 27 June 2022 Mr Harris deliberately suspended himself [REDACTED], resulting in his death. In doing so he acted with the intention of taking his own life, albeit whilst suffering from a relapse of his paranoid schizophrenia.
Mr Harris would not have taken his own life had he remained well and the relapse of his Paranoid Schizophrenia materially contributed to his death. The relapse was precipitated by the initial reduction of his anti- psychotic medication in February 2022 and sped up and exacerbated by the further premature reduction in May 2022.
Mr Harris would not have died had an inpatient psychiatric hospital bed been available on either 24, 25 or 26 June 2022. | The circumstances of Mr Harris�s death are set out in the above narrative conclusion. | COPIES
I have sent a copy of this report to the following:
�
Chief Coroner
Mr Harris�s family
Mr Harris�s executor
Surrey and Borders Partnership NHS Foundation Trust
Comfort Care Services Ltd
Surrey County Council | Suicide (from 2015)
This report is being sent to: NHS England | |
06/03/2024 | 2024-0272 | Iain Hughes | Black Country | Channel Swimming Pilot Federation c/o Keystone Law
[REDACTED] � Pilot of the �Anastasia� | On 27 July 2023, I commenced an investigation into the death of Mr Iain Hughes dob 7 July 1980 who died on the 4 July 2023. The investigation concluded at the end of the inquest on 8 February 2024. �
The inquest was heard before myself sitting without a Jury and my conclusion at inquest was one of Misadventure. �
The medical cause of Mr Hughes death was recorded as 1a) Consistent with Drowning | Mr Hughes planned to do a channel swim to raise money for several charities. As part of this preparation they were in touch with the Channel swimming and piloting Federation (CSPF) for guidance and to organise a pilot to escort him across the channel.�
The pilot was, [REDACTED] and the crew on the �Anastasia� boat. �
The initial plan was to do the swim on 4-5 June 2023, but this was postponed to 19 June.� On the day of the swim they were met by [REDACTED] and the CSPF observer, [REDACTED]. They were given an informal briefing about the swim. [REDACTED] described this briefing as fragmented. She said she didn�t recall any discussion of Iain�s safety checks, warning signs to look out for and when the swim would be aborted. �
During the early parts of the swim he made good progress and was on target for a record swim. The family assisted by preparing his feeds every half an hour. His progress and key observations were recorded on a log by [REDACTED]. �
Later his pace started to slow down and dropped from 54 strokes per minute to 51. At approximately 11 hours and 35 minutes into the swim he became submerged in the water.
Despite attempts at rescue and further searches by the coastguard he wasn�t recovered.
�
The family and the crew then returned to Dover and statements were taken by the Police.
�
Mr Hughes was then subsequently found in Belgium waters in Oostende on the 4 July 2023. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The family of Mr Iain Hughes.
�
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: Channel Swimming Pilot Federation | Anastasia Boat | |
21/06/2024 | 2024-0362 | Thomas Geraghty | East Sussex�
�
Category: Suicide (from 2015)�
�
This report is being sent to:�Chelsfield Surgery | Chelsfield Surgery�Chelsfield Surgery | On 04 July 2023 I commenced an investigation into the death of Thomas Joseph GERAGHTY aged 39. The investigation concluded at the end of the inquest on 21 June 2024.
The conclusion of the inquest was:
Suicide | On the morning of 28 June 2023 Thomas Joseph Geraghty entered the sea from the beach at Eastbourne. He was not witnessed entering the water. At around 11:45, Mr Geraghty�s body� was� seen� floating� by� a� nearby� lifeguard� and� he� was� recovered� to� the� beach. Resuscitation was attempted however it was sadly unsuccessful and death was confirmed. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Mr GERAGHTY�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 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)�
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| |
21/01/2025 | 2025-0035 | Carl Butler and Sean Brett | North Wales (East and Central) | Cheshire Constabulary, Clemonds Hey, Oakmere Road, Winsford, CW7 2UA | On the 28th of February 2022 I commenced investigations into the deaths of Carl Anthony Butler (DOB 19.10.67 DOD 26.02,22) and Sean Brett (DOB 03.01.72 DOD 26.02.22) . The� investigations concluded at the end of the inquest on the 17th of January 2025. In relation to�both deaths, I returned narrative conclusions as follows:�
For Mr Butler � On the 26th of February 2022 whilst intoxicated, the deceased drove his vehicle in the wrong direction along the A55 at Broughton and into collision with an oncoming vehicle,� sustaining unsurvivable injuries, and as a result he was verified dead at the scene.�
For Mr Brett � On the 26th of February 2022 on the A55 at Broughton, the deceased was the� driver of a motor vehicle which was struck by another vehicle which was being driven in the� wrong direction on the carriageway by a person who was over the prescribed drink driving limit. As a result of the collision Sean Brett sustained injuries which were incompatible with life and� was declared deceased at the scene. | On the 12th of February 2022, Carl Butler had been arrested, charged and bailed by Cheshire Constabulary in relation to a drink-drive offence.�
At approximately 05.15 on the 26th of February 2022, Cheshire Constabulary received report of�
an intoxicated driver leaving a petrol station in Chester. (This was Mr Carl Butler driving a vehicle registered to him).�
A report was put out requesting observations for this vehicle but the car and driver were not located.�
At approximately 11.45 the same day, Cheshire Constabulary received a further report in relation to this vehicle and to the erratic manner in which it was being driven.�
Around 30 mins later, Mr Butler drove his car the wrong way along the A55 dual carriageway,� colliding with Mr Brett�s� vehicle coming in the opposite direction, resulting in both their deaths.
Subsequent tests established that Mr Butler was more than four and a half times the prescribed drink drive limit at the time of the collision. | I have sent a copy of my report to the Families of the Deceased and to the Chief Coroner.
��
I am also under a duty to send the Chief Coroner a copy of your response.��
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.� You may make representations to me, the coroner, at the time of your response, about the� release or the publication of your response by the Chief Coroner. | Road (Highways Safety) related deaths | Wales prevention of future deaths reports (2019 onwards) | Cheshire Constabulary |
30/04/2024 | 2024-0239 | Kellie Sutton | Cambridgeshire and Peterborough | Chief Constable for Hertfordshire Constabulary | On 02 September 2021 I commenced an investigation into the death of Kellie Marie SUTTON. �
Kellie died on 26 August 2017 in Lister Hospital. She was 30 years old. The investigation concluded at the end of the inquest on 06 July 2023. The medical cause of death was 1a) features consistent with hanging. �
The jury recorded a short form conclusion of unlawful killing and a narrative conclusion as follows: �
After being subjected to months of controlling and coercive behaviour and domestic abuse by her then partner, on the morning of 23rd August 2017 Kellie Sutton hung herself [REDACTED] �She was treated at the scene by ambulance staff and HEMS before being conveyed to the Lister Hospital. Her injuries were not survivable and she died at 2.30pm on 26th August 2017 in the hospital. �
The jury found that there were certain failures or inadequacies by Herfordshire Constabulary which may have contributed to Kellie Sutton�s death, but not that they did: see Annex A � Determination sheet. | Kellie Sutton had experienced a series of relationships from a young age with abusive men in the past. She had 3 children. Kellie met her final partner in March 2017 and he moved in to her home [REDACTED] where she lived with two of her children in a shared custody arrangement. �
There was extensive and detailed witness evidence gathered by the police for criminal proceedings which demonstrated that Kellie�s partner was abusive towards her: both physically violent on at least several occasions and by his controlling and coercive behaviour towards her, which included shouting, threatening, phoning constantly if she was out, isolating her from her family and friends and holding her bank card.�
She lived in fear of her phone battery dying because if he couldn�t get hold of her he would �go mad� and would become violent. In March 2018, i.e. after her death, Kellie�s partner was convicted of controlling and coercive behaviour in an intimate relationship, contrary to s76 of the Serious Crime Act 2015, the offence taking place between 1 March 2017 and 24 August 2017. He was also convicted of one count of assault occasioning actual bodily harm, the offence taking place on 3rd June 2017 and one count of common assault which occurred on 9 July 2017.
�
I am satisfied from the evidence, which included text messages from Kellie to friends and from Kellie to her partner that Kellie was very unhappy in this relationship but did not feel able to extricate herself from it, even though her friends were telling her he was abusive.
�
On 9 July 2017 a neighbour called the police on the basis that Kellie was being �beaten up by her partner�. The police came very quickly and spoke to Kellie and her partner separately but the couple told them that they had just had a verbal argument. A risk assessment in the form of the DASH book was completed which resulted in 6 ticks and the police took the view that this was a �standard risk� case and the matter was closed as a non-crime incident. The police did not speak to the neighbour who called 999 and who was in possession of significant further information about the incident, including that one of the children had witnessed it. In a witness statement for the inquest the police accepted, at a senior level, that the response fell below the expected standard in a number of respects, including body worn video capability, the failure to check up on the children and that they showed a lack of professional curiosity and judgment relating to the DASH process and house to house inquiries not being completed.
�
The controlling and coercive behaviour continued. Over the night of 22/23 August 2017, there were a series of exchanges both verbally and by text message which continued after Kellie�s partner left for work at 650 a.m. This showed a series of increasingly distressed messages from Kellie culminating in her threatening to hang herself to which he had responded with words to the effect of �do everyone a favour�. Very shortly thereafter she stopped answering the phone, he rushed home and found her hanging [REDACTED] , at about 810 a.m. Despite him administering CPR to her and the ambulance arriving shortly thereafter, tests showed that she had suffered irrecoverable brain injury from lack of oxygen and brain stem death was confirmed on 26 August 2017 when she was pronounced dead.
�
The inquest jury found that although they were not satisfied that the lack of further investigation or action on 9 July 2017 did contribute to Kellie Sutton�s death, they found that it may have led to further interventions that could have altered the final outcome on 23 August 2017. The jury also found that numerous opportunities were missed at several levels to recognise the significance of the responses in the DASH and that this in turn led to a failure to consider implementation of appropriate protective measures, which could have included issuing a DVPN and/or applying Clare�s law. However, they concluded that they could not be satisfied that these failings did contribute to Kellie Sutton�s death, although they may have contributed to her death.
�
During the course of the inquest the court heard evidence from an expert in the field of violence against women and girls about the harms of controlling and coercive behaviour and abuse, the feelings of entrapment by victims meaning it was very common for a victim to be unable to extricate themselves and the higher incidence of suicide in victims of abuse: one third of all suicides in England and Wales are preceded by domestic abuse. The court heard that an understanding of controlling and coercive behaviour was key to any risk assessment and that it was important to understand that no physical assault was required.
�
The evidence at the inquest indicated a lack of awareness of the link between domestic abuse and suicide. Whilst officers did have an awareness of the �harm� from others through domestic abuse, a heightened awareness of the risk of �harm� by taking one�s own life was relevant to a risk assessment and the consequential steps which may be required.
�
The evidence at the inquest also appeared to reveal a lack of understanding by front line officers of the circumstances in which a DVPN could be applied for, and whether it was necessary for an individual to have been subject to arrest prior to triggering a referral to the DAISU I am of the view that this lack of understanding, notwithstanding training which had been provided, was evident and created a risk of future deaths.
�
The court heard about the lack of systems available at the time to easily identify serial perpetrators of abuse. However, I accept the evidence from the Constabulary about the changes that have already been made and further developments that are on-going.
Accordingly this element does not form one of my elements of concern. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
Family of Kellie Sutton.
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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: Hertfordshire Constabulary | |
11/01/2023
| 2023-0013 | Leroy Hamilton | Birmingham and Solihull
| Chief Constable for West Midlands Police
Birmingham and Solihull Mental health NHS Foundation Trust
Birmingham and Solihull Integrated care board
University Hospital Birmingham NHS Foundation Trust
Secretary of state for Health | On 18 January 2022 I commenced an investigation into the death of Leroy Patrick HAMILTON. The investigation concluded at the end of the Inquest.
The conclusion of the Inquest was: Drowned whilst suffering an acute psychotic relapse | Mr Hamilton was known to suffer from reactive depression and psychosis and had been under the care of the mental health team since 2017 when he was detained under the Mental Health Act having deliberately self-harmed by stabbing. Since that time, he had been under the care of the community mental health team with a period of care under the home treatment team in July 2021 following a short admission for a relapse in his condition. At his last review in September 2021, he was noted to be well but concern was expressed about lack of compliance with medication due to some side effects. On 02/12/21 he was noted by a resident at his shared accommodation to be hallucinating, having smashed a window and threated to eat the glass. Police and paramedics attended and he was taken to Good Hope Hospital emergency department where he arrived at 01.45. He was assessed by the mental health liaison service and a psychiatric doctor as needing a full Mental Health Act assessment which was undertaken at 11.30 on 03/12/21. The assessment concluded that he did require further treatment due to a relapse in his condition caused by non- compliance with his medication. He agreed to a voluntary admission, further assessment and recommencement of his medication. He remained in the Emergency department whilst attempts were made to find a bed. At the time there was a national shortage of mental health beds. Staff from the hospital notified the police that he had left the department at 13.41 and that he was at risk of harming himself. There was a failure to treat Mr Hamilton as a missing person at this time, a failure by the mental health services to refer him to the home treatment team for a safe and well check and he was not assessed by the street triage team. At 18.58 police were notified by his landlord that he had left his property following a mental health episode and he was reported to have drunk bleach. No action was taken in relation to this log. At 19.51 police found Mr Hamilton walking on the footpath alongside the dual carriageway near The Fort shopping village after a member of the public reported seeing a man walking in the road. Mr Hamilton reported to officers that he suffered from depression and was out walking to clear his head. Police noted that he was cold and wet and had recently been assessed at Good Hope Hospital and he agreed to be taken to Birmingham Heartlands hospital for further assessment. At the hospital he was triaged by a nurse and noted to be suicidal. He was taken to the escalation room to wait to be assessed. He was not seen again and was noted to be missing from the department at 05.28 on 05/12/21. It is not known when he left the department. There was a failure to report him missing at this time. On 06/12/21 the deceased was found by a member of the public who was walking his dog, in the middle of the river�[REDACTED] �Stechford lying on his back on a rock. He was confirmed deceased at the scene by�[REDACTED] at 12.20. His whereabouts since he left the emergency department on or around 4/5th December 2021 are unknown and whilst he had previously indicated suicidal ideation, his intentions at the time of his death are unknown. There were several failures in his care which amount to missed opportunities to help Mr Hamilton; however, it is not possible to say whether the outcome could have been different.
�
Following a post mortem, the medical cause of death was determined to be:
1a Drowning 1b Psychosis | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons : The family of Mr Hamilton
I have also sent it to the Medical Examiner, NHS England, who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Other related deaths
| West Midlands Police | Birmingham and Solihull Mental Health NHS Foundation Trust | Birmingham and Solihull Integrated Care Board | University Hospital Birmingham NHS Foundation Trust | Department of Health and Social Care |
06/10/2023 | 2023-0374 | John Condron | Cheshire | Chief Constable of Cheshire police
National College of Policing
National Police Chiefs� Council | On 08 November 2017 I commenced an investigation into the death of John George CONDRON aged 53.
The investigation concluded at the end of the inquest on 25 September 2023. The conclusion of the inquest was that: �
Narrative Conclusion � John George Condron took his own life whilst suffering extreme anxiety and stress in respect of allegations made against him which were being investigated by the police. This was exacerbated by
i) him not having been informed that no further action was to be taken in respect of the most serious allegation against him, despite that decision having been made 10 days previously; and
ii) no enquiries having been made in respect of evidence he referred to in his police interviews. | On the 2nd November 2017, John Condron was found at his home address suspended from the roof beams in his loft by a ligature around his neck made from a rope. At the time of his death he was under investigation by the Police, allegations having been made against him by his ex-partner but prior to these allegations being made, Mr Condron had reported to the police that he was the victim of domestic abuse by that same partner. Mr Condron had been interviewed by the police on three separate occasions in relation to two different allegations. On the 23rd October 2017 the decision was made to take no further action in relation to the most serious of those allegations. Mr Condron had not been informed of that decision which exacerbated the extreme anxiety and stress he was experiencing at the time of his death. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
I have also sent it to:
�
The Chief Coroner;
The family of John George Condron
Chief Constable of Cheshire Police
National College of Policing
National Police Chiefs� Council
�
who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015)
This report is being sent to: Cheshire Police | National College of Policing | National Police Chief�s Council | |
15/05/2023 | 2023-0154 | Rebecca Fisher | Manchester South | Chief Constable of Greater Manchester Police | On 19th April 2022 I commenced an investigation into the death of Rebecca Alice Fisher. The investigation concluded on the 18th April 2023 and the conclusion was one of Suicide.
The medical cause of death was
1a) Drug Toxicity | On 15th April 2022, Rebecca Alice fisher was found deceased by her family in a secluded area of Reddish Vale. Post-mortem examination included toxicology. She had a fatal dose of drugs in her system including pregabalin. [REDACTED] Rebecca had been reported by the Norbury Ward to Greater Manchester Police (GMP) as a high-risk missing person on the 11th April at about 6pm after she failed to return from 30 minutes of unescorted leave. Rebecca had a complex mental health history [REDACTED]. She had been admitted to the Norbury ward as a crisis patient. [REDACTED]. She had been allowed to leave for 30 minutes of unescorted leave. It was recognised that this presented a risk. Her failure to return was correctly assessed by hospital staff as creating an escalated risk and a high-risk situation. Greater Manchester Police failed to correctly assess her as a high-risk missing person. As a consequence, this meant that mobile telephone enquiries were not immediately undertaken, and the investigation did not have specialised input in the hours immediately following her being reported missing. It is probable that if these enquiries had taken place Greater Manchester Police would have known she was in the area of her home address and Reddish Vale. It is possible that Rebecca would have been found before she died had she been treated as a high-risk missing person. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely 1) [REDACTED] on behalf of the Family; 2) Pennine Care, who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015)
This report is being sent to: Greater Manchester Police | |
24/12/2024 | 2024-0710 | Paul Taylor | Nottingham and Nottinghamshire | Chief Constable of Nottinghamshire Police | On 29th April 2024 an inquest was opened into the death of Paul Ian Taylor, aged 58. The inquest concluded on 17th�December 2024. I made a determination at inquest that he died as a result of suicide. | Paul Taylor had been under police investigation for offences that necessitated consideration of the Suicide Prevention and Risk Management of Suspects policy, Nottinghamshire Police document PS260, by the police. That policy was complied with. It was appropriate not to arrest Mr Taylor at the outset of the investigation, so he was voluntarily interviewed and he was released under investigation for a two year period. Within a fortnight of him being made aware that criminal charges had been authorised, he intentionally took a large quantity of prescription medication and was found deceased at his home address on 3 January 2024. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
Paul�s family.
�
I have sent a copy of the report to the College of Policing as I believe they may find it useful or of interest.
�
I am under a duty to send the Chief Coroner a copy of your response and all interested persons who, in my opinion, should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Police related deaths | Suicide (from 2015) | Nottinghamshire Police |
24/09/2024 | 2024-0511 | Ryan Ouslem | West Sussex, Brighton and Hove | Chief Constable of Sussex Police
CEO Sussex Partnership NHS Foundation Trust (SPFT) | On 11 August 2022 I commenced an investigation into the death of Ryan Louis Ouslem aged 34. The investigation concluded at the end of the inquest on 05 September 2024. The conclusion of the inquest was that:
On the 1st August 2022, Ryan Louis Ouslem died by [REDACTED] poisoning at the rear top floor flat,�[REDACTED]. On 29th July 2022 Ryan hired [REDACTED] and he hired [REDACTED] on 1st August 2022. He then took additional steps of [REDACTED], writing a suicide note and bank details and blocking entry to the property with large speakers.
He subsequently ran the [REDACTED] with the intention of ending his life by [REDACTED] poisoning. | Ryan lived alone. On Friday 29/07/2022 he put a post on Facebook which raised concerns
for his welfare and indicated that his flat was not safe to enter.� Police and fire services atttended and forced entry finding Ryan alive.� He denied any ongoing intent to harm himself.� The police offered Ryan a call from a mental health service nurse the following day and left the scene.
On Monday 01/08/2022 Ryan�s mother and partner could not get a response from Ryan.
The police and fire services attended and forced entry again.
Ryan was found deceased on his bed. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
The family of Ryan Ouslem
West Sussex Fire & Rescue Service
I have also sent it to n/a 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) | Sussex Police | Sussex Partnership NHS Foundation Trust |
12/08/2024 | 2024-0516 | Parminder Sanghera | Black Country | Chief Constable, West Midlands Police
Criminal Justice Mental Health Liaison Team, Midland�s Partnership Trust. | On 26 March 2023, I commenced an investigation into the death of Mr Parminder Singh Sanghera born on the 7 July 1980 who died on the 13 February 2023.� The investigation concluded at the end of the inquest on 16 July 2024.
�
The inquest was heard before myself sitting without a Jury and my conclusion at inquest was one of Suicide.
�
The medical cause of Mr Sanghera�s death was recorded as
�
1a) Compatible with a combination of drowning and [REDACTED] | At 5.23pm on 12 February 2023, a call was made to West Midlands Police to report a male running around naked in Wolverhampton.
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Mr Parminder Sanghera was detained and arrested for outraging public decency. He had a head injury and displaying behaviour that concerned officers about his mental health and was taken to New Cross Hospital in Wolverhampton.
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They arrived at hospital at 6.26pm and was discharged as fit for detention at 11.47pm after being treated.
�
Mr Sanghera was then taken to Oldbury custody suite where a risk assessment was undertaken, and his detention authorised at 12:34am on 13 February 2023.
�
Mr Sanghera was kept in custody throughout the night under level 3 observations and was seen by a Health Care Professional (HCP) during the night.
�
A decision was made to release Mr Sanghera without charge, and a pre-release risk assessment completed at 1.51pm on 13 February 2023, stated �no� for concerns about risk of suicide or self-harm following release.
The custody records further stated that Mr Sanghera was suffering from behavioural issues and that he had been reviewed by L&D (Liaison and Diversion) and assessed for mental health issues the day before. He was not found to warrant a full Mental Health Act assessment the previous day.
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Mr Sanghera was reported to be unwilling to leave and force was used to escort him from the cell and the custody suite by two police staff.
�
Transport arrangements were not deemed necessary, and it was stated that he was not showing signs of mental vulnerability.
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External CCTV footage showed that after Mr Sanghera left custody at around 1.55pm.� He stood outside the custody suite for a period. He then walked away from the custody suite and returned to the car park area numerous times. He was last seen on CCTV outside the custody suite at 3.52pm walking towards the canal towpath.
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At 5.00pm a log was created that a male had been found deceased in the canal near to Oldbury custody suite. He was discovered face down [REDACTED]. An ambulance attended and sadly life was pronounced extinct at 6pm at the scene. | I have sent a copy of my report to the Chief Coroner and to the following Interested Person, family of the deceased.
�
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. | Police related deaths | Suicide (from 2015) | Mental Health related deaths | West Midlands Police | Midlands Partnership Trust |
03/01/2023
| 2023-0002 | Beryl Ellison | Sefton, St Helens and Knowsley
| Chief Coroner�s Office,
CQC
[REDACTED], (Weightman�s Solicitors)
Four Seasons Health Care (HEAD OFFICE) | On 12 July 2022 I commenced an investigation into the death of Beryl ELLISON aged 75. The investigation concluded at the end of the inquest on 20 December 2022.
The conclusion of the inquest was that: �
Mrs Ellison was in declining health and was receiving end of life care. She was found deceased at Alexandra Care Home, Park Road, Newton-le-Willows, on 28th June 2022 as a consequence of her underlying poor health in combination with taking an excessive quantity of her prescribed medication. | Mrs Ellison had been in hospital and was discharged to the Alexandra Care Home for Palliative Care. A DNAR was in place. She had previously suffered with pneumonia and Septicaemia, and had an amputation of her leg and finger due to blood clots. Her family had been advised that there was nothing further that could have been done for her medically.
On the 28th of June 2022, at approximately 1000 hours, Mrs ELLISON had been due her medication around this time. One of the care workers went into her room to give her her medications and check on her, as it was unusual for Mrs ELLISON not to have not pressed the call button for her medications before this time. When the careworker went in, she noticed that Mrs ELLISON was very drowsy and sleepy. As such, she turned the lights on and noticed she was pale.
With this, the care assistant has took her observations, which were concerning. Consequently, she informed the registered staff nurse before calling for an ambulance. As the care assistant returned to the office to make her call, the registered staff nurse informed her that Mrs Ellison had already passed away and it was therefore too late.
As such, police and Mrs Ellison�s GP were called. The GP attended and pronounced time of death at 1352 hours.
Mrs Ellison�s son stated he had raised a concern to the care home 4-6 weeks ago about medication being left in his mother�s room, as she had been observed hiding it under the bed covers. He had been informed that the staff would administer the morphine and observe her taking it from then on. Mrs Ellison�s son was concerned that there had been no change in the care home practice since his earlier complaint, which may have led to his mother taking an accidental overdose of her medication. | Alcohol, drug and medication related deaths | Care Home Health related deaths
| CQC, Weightmans�s Solicitors and Four Seasons Health Care | |
13/09/2023 | 2023-0327 | Geoffrey Hoad | Norfolk | Chief Executive East of England Ambulance Service NHS Trust Whiting Way Melbourn Cambridgeshire SG86EN
The Secretary of State for Health and Social Care:
The Right Hon Steve Barclay MP
The Department of Health and Social Care
Spire Norwich Hospital/Spire Healthcare Limited | On 17 August 2022 I commenced an investigation into the death of Geoffrey Douglas HOAD aged 85. The investigation concluded at the end of the inquest on 07 September 2023. �
The medical cause of death was:
1a) �Sub Acute Myocardial Infarction
1b)�� Coronary Artery Atherosclerosis
1c)
2) Hospital Admission for Post Operative lieus �
The conclusion of the inquest was: Mr Hoad underwent an appropriate, elective medical procedure on 3 August 2022, following which a paralytic ileus was diagnosed. Mr Hoad�s condition fluctuated and did not respond to conservative management. The decision was made to transfer Mr Hoad to Norfolk and Norwich University Hospital at approximately 18.00 on 6 August 2022 and an ambulance called. The ambulance arrived at 08.26 hours on 7 August 2022. Mr Hoad�s condition continued to fluctuate. At 18.50 Mr Hoad rapidly deteriorated and he died at 23.45 hours. | On 3 August 2022, Mr Hoad underwent a total hip replacement at The Spire Hospital. On 5 August 2022, Mr Hoad was diagnosed with a paralytic ileus and some respiratory compromise with gradually deteriorating renal function. On 6 August 2022, Mr Hoad�s transfer to Norfolk and Norwich University Hospital was agreed due to possible bowel obstruction, possible pulmonary infection and deteriorating renal function. �
Ambulance service was called at 18:16 hours and again at 23.45. On 7 August 2022, the ambulance service was called again at 07.38 hours. The ambulance was on scene at 08:26 hours. � � � �
Mr Hoad was transported to Norfolk and Norwich University Hospital. At 11.30 am ECG was undertaken which showed signs of cardiac ischaemia. The evidence does not reveal whether this ECG was reviewed. The cardiac ischaemia was not noted and acted upon at this time. By 18.52 Mr Hoad had clinically deteriorated with continued low blood pressure and increased oxygen requirements. A repeat ECT showed ongoing ischaemia which was recognised and Mr Hoad was taken to Critical Care Complex at 20.18 hours with a diagnosis of myocardial infarction. Despite treatment, Mr Hoad continued to deteriorate and he died later that day on 7 August 2022. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
Hospital Spire Healthcare Limited
Norfolk and Norwich University Hospitals NHS Foundation Trust I have also sent it to:
Department of Health CQC
HSIB
Healthwatch
NHS England & NHS Improvement who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths | Emergency services related deaths (2019 onwards)
This report is being sent to: East of England Ambulance Service NHS Trust | Department of Health and Social Care | Spire | |
14/08/2023 | 2023-0293 | Linda Oldland | Surrey | Chief Executive Leonard Cheshire 66 South Lambeth Road London SW8 1RL | INQUEST �
An inquest into Ms Oldland�s death was opened on 21 January 2022. The inquest was resumed and evidence was heard on 30 September 2022, 3 October 2022 and 30 June 2023. The inquest concluded on 3 July 2023. The medical cause of Ms Oldland�s death was: Ia Sepsis. Ib Bilateral pyelonephritis. Ic Bilateral renal calculi treated with bilateral ureteric stents � The inquest concluded with a narrative conclusion as follows:
Ms Oldland was a 61 year old woman who lived at Hydon Hill Nursing Home, run by Leonard Cheshire.
Ms Oldland had severe progressive multiple sclerosis and as a result she was bedbound and had minimal communication abilities. She also suffered from chronic kidney disease and kidney stones with bilateral ureteric stents, and a related history of recurrent urine infections.
On 3 January 2022 Ms Oldland died at Hydon Hill Nursing Home. Her death was due to a urinary tract infection which infected both her kidneys and resulted in sepsis. Her kidney stones and ureteric stents contributed to her developing the urinary tract infection.
On 31 December 2021 Ms Oldland�s GP from The Mill Medical Practice visited her at Hydon Hill Nursing Home. Given her history the GP thought she may be in the early stages of urinary sepsis. She therefore prescribed stand-by antibiotics to be commenced if Ms Oldland deteriorated, including by way of a reduction in consciousness levels. The GP also asked for Mrs Oldland to be admitted to hospital if she began to show signs of sepsis. This was in accordance with the wishes Ms Oldland had set out in her Proactive Anticipatory Care Plan (PACE). The GP also asked for a urine sample to be taken and delivered to the surgery for testing.
During the consultation with the GP on 31 December 2021, the staff at Hydon Hill Nursing Home did not inform the GP that Ms Oldland had had a positive urine dip stick test the previous day.
After the urine sample had been delivered to the GP surgery later that afternoon, staff at the GP surgery carried out a positive dipstick test before sending the sample off for further testing at the laboratory. Ms Oldland�s GP was not made aware of the second positive dip stick test.
In the event that that Ms Oldland�s GP had been informed of either of the positive dipstick test results, Ms Oldland would have been immediately commenced on oral antibiotics and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been.
On the evening of 31 December 2021, Ms Oldland�s consciousness levels deteriorated and from that point onwards until lunch time on 2 January 2022 there was a delay on the part of Hydon Hill Nursing Home in commencing the standby antibiotics.
In the event that the antibiotics had been commenced on 31 December 2021, Ms Oldland�s life would have been prolonged, albeit it is not known what her ultimate prognosis would have been.
On 2 January 2022 Ms Oldland�s blood pressure deteriorated and staff at the nursing home called 999 and an ambulance attended from South East Coast Ambulance Service (SECAMBS). Ms Oldland was not transferred to hospital and discharged back to the care of her GP.
Hydon Hill staff did not inform SECAMBS that Ms Oldland had had a positive urine dipstick test on 30 December 2021 and that the plan arising from the GP consultation on 31 December 2021 was for her to be admitted to hospital should she show signs of sepsis and that this was in accordance with Ms Oldland�s intentions as recorded in her PACE document.
In the event that this information had been passed on to SECAMBS Ms Oldland would have been transferred to hospital and her life would have been prolonged, albeit it is not known what her ultimate prognosis would have been.
Ms Oldland�s death was contributed to by neglect on the part of Hydon Hill Nursing Home. | The circumstances of Ms Oldland�s death are as recorded in the narrative conclusion set out above.
�
In addition, the court found that on 3 January 2022, the day that Ms Oldland died, a nurse checked on her at approximately 13:00 and found her to be pale and unresponsive and called an ambulance. Whilst waiting for the ambulance the nurse reported to the telephone operator that Ms Oldland was breathing very slowly and had a weak pulse.� As a result, life support measures were not implemented prior to the ambulance arrival. However, on the arrival of the ambulance paramedics found Ms Oldland to be cyanosed and in a state of cardiac arrest. They did not commence life support measures as they were informed by nursing home staff that Ms Oldland had a valid Do Not Attempt to Resuscitate (DNAR) form in place. Ms Oldland was declared deceased at 13:24.
�
The court found that Ms Oldland had in fact entered into cardiac arrest at some unknown point prior to the arrival of the ambulance crew. The court also found that Ms Oldland did not have a valid DNAR in place and her express wish, which had been recorded in her PACE form, was to be resuscitated in the event of a cardiac arrest.
�
It is of considerable concern that the trained nurses at the care home were unable to recognise that Ms Oldland was in a state of cardiac arrest. It is also a matter of considerable concern that staff did not know what Ms Oldland�s wishes were in the event of a cardiac arrest and therefore did not commence life support measures on 3 January 2022.
�
However, the court was not persuaded that life support measures would have materially improved Ms Oldland�s clinical course on 3 January 2022. Accordingly, the court was not persuaded that the absence of life support measures on 3 January 2022 contributed to Ms Oldland�s death. | COPIES
I have sent a copy of this report to the following:
�
1.���� Chief Coroner
2.�����[REDACTED] (Brother)
3.���� South-East Coast Ambulance Service (SECAMBS)
The Mill Medical Practice | Care Home Health related deaths
This report is being sent to: Leonard Cheshire | |
12/12/2024 | 2024-0685 | Thomas Burroughs | Essex | Chief Executive Mid & South Essex NHS Trust | INVESTIGATION
�
On 7 March 2024 I commenced an investigation into the death of THOMAS ADRIAN BURROUGHS, AGE 35. The inquest has not yet concluded, the inquest is adjourned part-heard. | Thomas Burroughs was a 35-year-old learning disabled man who was nonverbal with a medical history of Cerebral Palsy, Scoliosis and Pressure Ulcers and was nil by mouth with PEG feeding in situ. Mr Burroughs had prolonged admission in hospital from 6 September to 23 November 2023 and readmitted on 29 November 2023 and was treated for recurrent aspiration pneumonia. During his hospital admissions Mr Burroughs feeding regime was on hold for periods of time during his admission. Mr Burroughs underwent procedures that included insertion of� a Hickman Catheter and later a jejunal extension. Mr Burroughs died in hospital on 22 February 2024. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Family
Cambridgeshire University NHS Hospitals Trust
Hamelin Trust
LeDeR (Learning from Lives and Deaths- People with Learning Disability and Autistic People)
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths | Mid & South Essex NHS Trust |
26/01/2024 | 2024-0040 | Jeanine Huggins | Norfolk | Chief Executive Norfolk and Norwich University Hospital Colney Lane NORWICH NR4 7UY | On 20 May 2022 I commenced an investigation into the death of Jeanine Maria HUGGINS aged 68. The investigation concluded at the end of the inquest on 25 January 2024. �
The medical cause of death was:
1a)�Coronary Artery Atheroma
2)��Diffuse Large B Cell Lymphoma on treatment �
The conclusion of the inquest was: Natural causes | 1. Mrs Jeanine Huggins had a background medical history including hypertension, sclerosis and Raynaud phenomenon and a diagnosis in 2019 of diffuse B-cell lymphoma. �
2. Jeanine was cared for by the Royal Free Hospital in relation to the sclerosis and Raynaud phenomenon and this condition appeared to have been well controlled with treatment and improved her symptoms. �
3. The lymphoma was treated at the Norfolk and Norwich University Hospital (NNUH) and Jeanine responded well to treatment and went into remission in 2021, but sadly in March 2022 there was a relapse and chemotherapy commenced. �
4. Jeanine was admitted to NNUH on 3 May 2022. She had presented to ED with fever, vomiting and diarrhea and was dehydrated and with poor urine output. She had recently undergone chemotherapy. A provisional diagnosis of neutropenic sepsis was made pending blood results and she was given antibiotics and IV fluids and investigations were ordered. Blood tests later confirmed the diagnosis and she was given injections to stimulate white cell growth and a platelet transfusion. Blood results also indicated an acute kidney injury (AKI).
�
5. Jeanine was reviewed by the Renal team in relation to the kidney injury. They agreed the AKI was likely due to dehydration and sepsis and arranged some further tests. The injury may also have been linked to one of the necessary chemotherapy treatments recently received.
�
6. Jeanine remained under review and treatment and on 5 May microbiology results confirmed a pseudomonas infection in her blood and antibiotics were appropriately adjusted as a result.
�
7. Reviews by the Haematology and Renal teams showed signs of improvement over the following days and by the morning of 9 May Jeanine had been apyrexial for several days, her oxygen saturations were good, she did remain tachycardic but her blood pressure and physical examination were good and she no longer appeared dehydrated. Her renal function, while still severely impaired, had stabilised. Her neutrophil count was back in the normal range. Discussions were had with Microbiologists about the continuation of antibiotics for the bacterial infection with a plan to make arrangements for Jeanine to be managed safely at home.
�
8. A treating Consultant described the position at that point as her clinical trajectory being one of cautious improvement. She described her death as unexpected from a Haematology point of view.
�
9. Jeanine was reviewed by a Haematologist at 0910 hours on 9 May and her NEWS2 score was 5. This was largely due to fluctuation in the ongoing tachycardia. She confirms that Jeanine was not hypotensive, had a normal temperature and improving oxygen saturations on a small amount of oxygen.
�
10. Jeanine was being nursed in a side room due to being neutropenic previously and having diarrhea.
�
11. Over the night of 9 May, medications were given around 19:30 hours and then the nurse saw Jeanine again around 21:23 hours and states that medication was given and her buzzer was left within easy reach. Her NEWS score was 5 and was the same again at 23:00. This was not escalated to medical staff nor did it lead to hourly observations in accordance with Trust guidelines. Evidence was heard from a Ward Sister at the Trust regarding concerns over poor documentation and the failure to follow Trust guidelines with regard to action in response to raised NEWS scores. While expert evidence suggested this was not causative, evidence was heard regarding training and education at the Trust to address this concern.
�
12. When Jeanine was next checked at around 02:00 she was not breathing and had vomited. Despite appropriate attempts, Jeanine could not be resuscitated and was sadly declared deceased at 02:56 hours.
�
13. A Post Mortem gave cause of death as (1a) coronary artery atheroma (2) Diffuse large B cell lymphoma on treatment.
�
14. Independent expert evidence of a Consultant Cardiologist was that on the balance of probabilities, Jeanine had an arrhythmic sudden cardiac death and deterioration would have been rapid, a matter of minutes.
�
15. While, based on expert evidence it was not felt to be causative, one of the other issues upon which evidence was heard related to Jeanine�s ability to use her call bell due to her underlying sclerosis, which her family advised made it difficult for her. While it was found in evidence that Jeanine had on other occasions used her bell, it was accepted that no one checked during the evening of 9 May whether her bell was in a suitable position to enable her to use it. Evidence was also heard that while in the side room, Jeanine could not be seen by nurses or HCAs unless they specifically went into her room. The only method for patients in such side rooms to contact staff in the event of an emergency is therefore by the call bell.
�
16. Evidence was given by a Ward Sister on the use of side rooms and call bells. She agreed that the room Jeanine was in, and indeed many side rooms, mean that the patient within them is not visible to the nursing & HCA team unless they go in the room. That means that, if they are not able to mobilise, whether due to their condition or a sudden event, the only way for them to attract the attention of staff is to use their call bell. It was accepted that this means it is extra important to ensure that these patients are able to use their call bell. The Inquest was told that there is no risk assessment carried out before someone is placed into a side room. It was fully accepted that there are many reasons why a side room is necessary, including cases like Jeanine where the patient is vulnerable and at risk of infection, so a ward bay would not be appropriate. However, if there is no risk assessment, then this may pose a risk if they are unable to communicate with or be seen by staff. This makes ensuring the call bell can be used more important. Evidence was seen of a document in the notes that is completed when HCAs/nurses complete intentional rounding & this asks for it to be ticked to confirm that the �call bell is within reach & patient shown how to use and is able to use�. This is ticked on each occasion for Jeanine on all dates. However, evidence was that on 9 May it was not checked whether she could in fact use it (we do not know for other dates). There was no documentation regarding any difficulties she had, as there was no formal risk assessment required. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
[REDACTED] � husband
[REDACTED] � son
[REDACTED] � Family Legal Representative
[REDACTED] � Norfolk & Norwich University Hospital Legal
Representative
[REDACTED] � CQC Inspector
�
I have also sent it to
�
Care Quality Commission Department of Health Healthwatch Norfolk HSIB
NHS ENGLAND (NHS IMPROVEMENT)
�
who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Norfolk and Norwich University Hospitals | |
31/08/2023 | 2023-0314 | Nicholas Ledger | Inner North London | Chief Executive Officer College of Policing 1- 6 Citadel Place Tinworth Street London SE11 5EF | On 23 February 2023, JDP Stevens, HM Assistant Coroner for Inner North London, commenced an investigation into the death of Nicholas Leger, aged 32 years. The investigation concluded at the end of the inquest on 12 June 2023. �
I made a determination of death by suicide.
The medical cause of death was:
1(a) Suspension by ligature | Mr Leger had been the subject of a Metropolitan Police investigation following a criminal allegation made in March 2022.
�
He was arrested and interviewed under caution at the end of May 2022, following which he was bailed. That bail was converted to RUI (released under investigation) in August 2022. He attended voluntarily a further interview on 5 November 2022.
�
On 23 January 2023, the CPS authorised that he be charged. This led to the generation of a PCR (Postal Charge Requisition) which was posted to him on 16 February 2023. This did not arrive at Mr Leger�s address until after his death. However, Mr Leger learnt of the charge via his solicitor on the morning of 20 February 2023. Sometime between 7:30pm and 10:30pm on 20 February 2023, he took his own life.
�
He had previously attempted to take his own life on 23 March 2022, after he had learnt of the allegation made against him. The investigating officer (OIC) was aware of this as Mr Leger had disclosed it when asked questions regarding his mental health and welfare at the times of the two interviews he attended. Although he had indicated at the times of the interviews that he had no concerns regarding his mental health/welfare, he also stated on 5 November 2022 that his mental health had suffered since the alleged incident.
�
This was the last date that any assessment was made of his mental health. By the time that he was sent the PCR (charging him with an offence that carried a maximum life sentence), he had been �RUI�d� for almost 6 months and it was more than 3 months since there had last been any formal assessment by the police of his mental health and risk of suicide or self-harm. | I have sent a copy of my report to the following.
�
������� The parents of Nicholas Leger
������� HHJ Thomas Teague QC, Chief Coroner of England & Wales
�
I am under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of 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: College of Policing and Metropolitan Police | |
14/03/2024 | 2024-0152 | Zachary Taylor-Smith | Derby and Derbyshire | 1��� University Hospitals of Derby and Burton NHS Foundation Trust | On 24 November 2022 I commenced an investigation into the death of Zachary Victor TAYLOR-SMITH aged Less than 1 day. The investigation concluded at the end of the inquest on 12 March 2024. The conclusion of the inquest was that: �
Zachary Taylor-Smith (Zac) was born and died on the 17th of November 2022 at The Royal Derby Hospital. His birth had been induced preterm due to maternal health complications. During birth Zac contracted an infection. After birth his condition quickly deteriorated and he died at just 14 hours old. His death was contributed to by neglect in that: Despite being clinically indicated Zac�s mother was not offered intra partum prophylactic antibiotics at any time during the induction process by either the attending doctors or midwives.The fact that Zac was born more than 18 hours after the rupture of his mother�s membranes was not recognised at any time after birth and therefore its significance in relation to the risk of early onset neonatal infection was missed and antibiotics were therefore not considered when they should have been.Despite Zac showing persistent signs of respiratory distress and having feeding difficulties, both clinical indicators of early onset infection, he was not given antibiotics as he should have been in accordance with the hospital�s own and national guidance. | Zachary Taylor-Smith died on the 17th of November 2022 at Royal Derby Hospital. He was born after a planned induction of labour at 36 weeks. His mother was not given prophylactic antibiotics before birth as she should have been. �
Both the labour and neonatal wards were busy. �
Zac was born more than 18 hours after his mother�s membranes were artificially ruptured however the significance was not noted by either the midwife supporting the birth, or any professional involved in her care thereafter. �
Although signs of grunting and respiratory distress, which warranted a review, were escalated to the neonatal team, no neonatal review took place. The requirement for such review was not communicated to the incoming neonatology team at the point of handover.
�
Despite Zac showing persistent signs of respiratory distress and having feeding difficulties, both clinical indicators of early onset infection, he was not given antibiotics as he should have been in accordance with the hospital�s own and national guidance.
�
There was evidence of confusion about the significance of the four hour period after birth in relation to indicators of a deteriorating baby and the potential over emphasis placed on the possible innocuous explanation for grunting in that period.
�
Evidence was heard at the inquest about the culture that existed between the midwifery team and neonatologists and that their relationship was difficult, albeit it was not thought to have compromised Zac�s care. Given that the responsibility for checking and monitoring signs of infection in the newborn was not, from the evidence, placed on either the midwifery team or the neonatologists but was a joint one, the relationship that exists between the teams is of critical importance. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
[REDACTED]
[REDACTED]
University Hospitals of Derby and Burton
�
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. | Child Death (from 2015)
This report is being sent to: University Hospitals of Derby and Burton NHS Foundation Trust | |
26/05/2024 | 2024-0284 | David Scott | Cheshire | 1��� Warrington Hospital | On 11 October 2023 I commenced an investigation into the death of David SCOTT aged 68. The investigation concluded at the end of the inquest on 23 May 2024. The conclusion of the inquest was that: �
David Scott died as a consequence of naturally occurring disease contributed to by malnutrition and in part by a delay in the initial diagnosis and treatment of peripheral vascular disease. | On the 2nd February 2023, David Scott attended Warrington Hospital with a history of a non-healing wound to his knee and leg pain. He was diagnosed with a right knee wound infection and discharged with antibiotics. On the 9th February 2023, David was seen by the physiotherapist who reviewed his x-rays and noted some vascular calcification, it was identified that David presented with risk factors for peripheral vascular disease and so it was requested that further investigations be carried out which resulted in an urgent referral being made to the vascular team on the 8th March 2023. � By the 4th April 2023, David�s knee wound had increased in size, showing no signs of healing, he was in pain and struggling with his mobility. At this time he had not had any communication in respect of the referral and so attended the Accident and Emergency Department at Warrington Hospital where the non healing ulcer on his right knee was noted, along with swelling and redness to both legs. David was admitted for review by the vascular team and on the 7th April 2023, investigations confirmed chronic limb threatening ischaemia in both of David�s legs in the context of peripheral vascular disease, at which time, surgical treatment options including revascularisation and endovascular were considered appropriate. � By the 14th April, David�s required assistance to mobilise and there was a deterioration in the wound to his knee with it appearing black and more inflamed with further blackened wounds appearing on his heel and ankle. During the period of deterioration, David�s wounds were not reviewed by the tissue viability nursing team as no referral had been actioned. On the 18th April 2023, David was treated with antibiotics for infection and when he was seen by the vascular surgeon on the 21st April, the condition of his leg had deteriorated to the point of ischaemic gangrene which had become so severe that he required an above the knee amputation as his leg was beyond repair. On admission, David was considered to be at high risk of malnutrition and during the admission, he lost weight following a reduction in his oral intake.
�
On the 26th April 2023, David was transferred to the Countess of Chester Hospital for surgery and on arrival it was noted that he had already started to develop deep tissue injury to his hip and buttocks. In the weeks that followed, amputation surgery was completed along with bypass surgery for revascularisation of his lower limbs. David continued to lose weight and experience difficulties with his skin integrity. He required 24 hour nursing care and was transferred to Green Park Nursing home to enable his wounds to heal with a view to his care eventually being moved back into the community. Whilst at Green Park, David gained weight and some of his wounds improved, however by the end of September, David was struggling to manage his pain, he looked pale and tests indicated that he had developed an infection.
�
On the 30th September 2023, David was admitted to Warrington Hospital with a diagnosis of infected ulcers and osteomyelitis. He did not respond to treatment and so palliative care commenced, following which, his condition deteriorated and he passed away on the 7th October 2023. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
[REDACTED]
�
I have also sent it to
�
who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person who I believe may find it useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
�
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths
This report is being sent to: Warrington Hospital | |
08/05/2024 | 2024-0251 | John Bass | Surrey | 1���� Chief Executive at Surrey County Council | On 13 December 2022 I commenced an investigation into the death of John William BASS aged 80. The investigation concluded at the end of the inquest on 30 April 2024. The conclusion of the inquest was that: �
Mr John William Bass died of head and chest injuries, at the age of 80 years of age, on A217 Brighton Road Tadworth, following a road traffic collision with a vehicle whilst he was riding his bicycle on 6th December 2022. | On 6th December 2022 Mr Bass, a fit and active cyclist fell from his bicycle on 6th December 2022 from the pavement on A217 Brighton Road, Tadworth, Southbound into approaching vehicle resulting in head and chest injuries from which he died. My conclusion was Road Traffic Collision. �
Surrey County Council is the highway authority responsible for the maintenance of this part of the public highway (the �Highway Authority�). �
A subsequent police investigation identified the footpath from which Mr Bass fell measured approximately 1.4 meters in width. However, due to the encroachment of mud/grass, twigs and acorns over the pavement space where Mr Bass was able to cycle it only measured 0.6 meters wide. � The Highways Authority confirmed in witness evidence, which was accepted under rule 23, that the A217 Brighton Road, Tadworth is subject to a yearly inspection. �
At the inquest the family advised that the footpath is used regularly by cyclists to avoid the vehicles on the busy road, where the speed limit is up to 40mph. This stretch of highway was said to have last been inspected on 14th November 2022 by car. A second scheduled inspection took place by foot on 22nd November 2022, just prior to the accident on 6th December 2022. The inspections did not identify any safety defects meeting the intervention level set out in Surrey County Council�s policy. I am informed by the family shortly after the accident the pavement was cleared. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
[REDACTED] � son
Surrey County Council
�
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: Surrey County Council | |
04/09/2023 | 2023-0317 | Emma Morrissey | Cheshire | 1���� Regenesis Health Travel Limited | On 28 July 2022 I commenced an investigation into the death of Emma Louise MORRISSEY aged 44. The investigation concluded at the end of the inquest on 31 August 2023. The conclusion of the inquest was that: �
Narrative Conclusion � Died as a result of a massive uncontrolled bleed caused by an instrument perforation within the abdomen during surgery. | On 06 July 2022 Emma Louise Morrissey flew to Turkey�s private Termessos Hospital in Antalya for gastric sleeve surgery. Arrangements were made through a health tourism company Regenisis. On 07 July 2022 Emma was operated. The surgeon perforated her abdomen with an instrument. The area was packed to stem the bleed but no platelets for blood clotting were administered causing continued bleeding and her sad death on 08 July 2022 at 12: 45 hours. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
Warrington Borough Council
Private Termessos Hastanesi
[REDACTED]
[REDACTED]
I have also sent it to
�
Foreign, Commonwealth & Development Office
�
who may find it useful or of interest.
�
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
�
I may also send a copy of your response to any person� who I� believe may find it� useful or of interest.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Other related deaths
This report is being sent to: Regenesis Health Travel Limited | |
19/12/2024 | 2024-0697 | Andrew Lewis | Berkshire | 1�����Secretary of State for Health and Social Care.
2��� Chief Executive, NHS England. | INVESTIGATION
On 22nd of May 2024 I opened an inquest into the death of Andrew Michael Lewis. The inquest was conducted on 6th of December 2024.
The cause of death was:
1a) Acute on Chronic Gastrointestinal Haemorrhage 1b) Bleeding Oesophageal Varices
1c) Alcoholic Liver Cirrhosis
2) Low volume Subdural Haemorrhage
The conclusion of the inquest was:
Alcohol-related, contributed to by head injury. | Andrew Lewis was a 55 year old man who died at home on the 7th of May 2024. He called 111 at 13:42 on 7th of May 2024, reporting weakness in his legs and an earlier fall.
The key times are:
13:42��Called 111, categorised as Category 3 (ie response time within 120 minutes for 90% of calls).
This decision required confirmation by a clinician within South Central Ambulance Service (�SCAS�), as the original call was to 111.
15:17 SCAS categorised the call as Category 3.
The 120 minute �clock� began to run at this point.
An ambulance should therefore have been in attendance by 17:17.
23:45� Ambulance arrived. Andrew was deceased. This ambulance arrived because family and police had attended the property, broken in and found him unresponsive � the call was then categorised as Category 1 (the most urgent category).
I accepted at inquest that the reason for this chronology was that there was simply no ambulance to send earlier. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons or organisations who may find it useful or of interest:
1.�Andrew�s family.
2. South Central Ambulance Service NHS Foundation Trust.
3.�Association of Ambulance Service Chief Executives.
For the avoidance of doubt, a response is only requested from the two recipients referred to at the top of this report.
I am also under a duty to send the Chief Coroner a copy of your responses.
The Chief Coroner may publish either or both in a complete or redacted or summary form.� He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Emergency services related deaths (2019 onwards) | Department of Health and Social Care | NHS England |
10/01/2025 | 2025-0018 | Jan Raciborski | Berkshire | 1��������� CEO, Oxford Health NHS Foundation Trust | On 09 February 2024 I commenced an investigation into the death of Jan Michael RACIBORSKI aged 62. The investigation concluded at the end of the inquest on 10 January 2025. The conclusion of the inquest was that:
On the 5th February 2024 Jan Michael Raciborski died at his home address in Caversham after he hung himself.� He had suffered with mental health issues for the majority of his life which, along with the impact of a brain injury resulting from an historic attempt to end his life, significantly affected his mood and decision making processes. | Mr Raciborski suffered from depression and a brain injury for many years.� This led to a complex presentation and he was under the care and treatment of the South Oxon Adult Mental Health Team (AMHT) from 2022.� He had previously been sectioned, spent time as a voluntary patient and the mental health services had had involvement on and off over the past 40 years.
The AMHT worked closely with Mr Raciborski and he had both a care co-ordinator and support worker, as well as involvement with further staff members.� He had many contacts with them during his final period of care.
He had a history of impulsive actions and intermittent suicidal thoughts.� In August 2023 his condition deteriorated before then improving.� In November 2023 this happened again and this presentation was in keeping with a pattern over the years.
In January 2024 he had a fleeting thought of suicide and was assessed by a mental health team in London.� He subsequently had contact with his local AMHT.� He remained distressed over the following days until he was found deceased on the 5th February 2024. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Mr Raciborski�s family.
I have also sent it to
who may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Suicide (from 2015)�| Mental Health related deaths | Oxford Health NHS Foundation Trust |
13/01/2025 | 2025-0021 | Angela Carney | West Yorkshire Western | 1��������� Department for Transport
2��������� Medicines & Healthcare products Regulatory Agency (MHRA) | On 04/10/2024� I opened an inquest into the death of Angela Stacey Carney who, at the date of her death was 65 years old. The inquest was resumed and concluded upon 07/01/2025.
I found the cause of death to be:- 1a. Chest injuries
The conclusion of the inquest was Road Traffic Collision.
With a finding in box 3 that:
On 26/09/2023 Angela Stacey Carney sustained fatal injuries after she emerged at speed on her mobility scooter from Westcliffe Road junction and into the path of a vehicle being driven along Westgate.� It is found more likely than not that she inadvertently placed her scooter into freewheel drive and this prevented her from braking or taking evasive action. | On the afternoon of 26/09/2023, Angela left her home address on her 2005 model Monarch Compact special edition, 4 wheel, single seater mobility scooter.�� Before setting off she moved her scooter out of her front garden and onto the footpath on Westcliffe Road by activating the free wheel mode via a lever near the rear wheel.
Westcliffe Road has a 4.7% downward gradient on the southerly approach to a give way junction with Westgate.� Angela, contrary to the instruction manual did not take the scooter off the free wheel drive by engaging the engine with her ignition key.� As a consequence, she was unable to stop the scooter because the brakes could only be activated by engine engagement.� This resulted in the scooter proceeding down the footpath of Westcliffe Road at speed towards the junction with Westgate and directly into the path of a Nissan Navana pickup, resulting in her suffering severe injuries to which she sadly succumbed notwithstanding treatment at the hospital and died. It was found that the circumstance of the collision was such that it prevented the driver of the Nissan from taking evasive action.
At the inquest it was noted that Angela had previously purchased the scooter second hand from her neighbour and that it was not manufactured with a secondary (independent) braking mechanism.� The scooter was found to be roadworthy and without any defects to have contributed to the collision and if the instruction manual had been followed, the scooter it could have been used safely.
That said I was concerned to find that there was no fail-safe breaking mechanism on the scooter to enable an emergency stop to take place in the event of the inadvertence of the rider. | 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. | Product related deaths | Road (Highways Safety) related deaths | Department for Transport | Medicines & Healthcare products Regulatory Agency |
13/01/2025 | 2025-0022 | Tobias Barraclough | West Yorkshire Western | 1��������� Department for Transport
2���������[REDACTED] (Secretary of State for Transport) | On 01/11/2023 I opened an inquest into the death of Joseph Samuel Walsh who at the date of his death was aged 19 years old. In addition upon 22/11/2023 I opened the inquest into the death of Tobias Crowther Barraclough, who at the date of his death was aged 18 years old. Their inquests were adjourned and both resumed and heard together and concluded by me on Tuesday 17th December 2024.
In the case of Joseph Samuel Walsh I found that the cause of death to be: � 1a Head Injuries
In the case of Tobias Crowther Barraclough I found the cause of death to be:-
1a Severe traumatic and hypoxic brain injuries
1b Road Traffic Collision causing injuries to the brain face and chest
The conclusion of both inquests was Road Traffic Collision | On 20/10/2023 Joseph Samuel Walsh was driving his motor car and carrying Tobias Crowther Barraclough along with 3 other passengers [REDACTED] (aged 18), [REDACTED] (aged 18), [REDACTED] (aged 18) and [REDACTED] (aged 17). All had been previously celebrating a birthday in a local public house and consumed alcohol.� Joseph�s post mortem found that he had consumed both alcohol and cocaine, which would have placed him over the legal limit to drive.� As Joseph drove the car along Brow Lane, Shelf, Halifax, a residential road with a 20mph speed limit, he lost control of the vehicle and collided with a wall, causing him to instantaneously sustain fatal injuries from which he died at 23:54.
Sadly, although Tobias was taken to hospital, he later succumbed and died from his injuries upon 12/11/2023.
The surviving passengers sustained injuries as a result of the collision. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
[REDACTED] � Joseph�s father
[REDACTED] � Joseph�s mother
[REDACTED] � Tobias� father�
[REDACTED] � Tobias� mother
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. | Road (Highways Safety) related deaths | Department for Transport |
31/01/2025 | 2025-0053 | Nicola Owens | Liverpool and Wirral | 1��������� Department of Health and Social Care
2��������� NHS England & NHS Improvement
3��������� The Chief Coroner | On 07 October 2024 I commenced an investigation into the death of Nicola Emma OWENS aged 40.� The investigation concluded at the end of the inquest on 30 January 2025.� The conclusion of the inquest was that:
Cause of Death
1a. Hyperosmolar Hyperglycaemic State
b. Undiagnosed Type 2 Diabetes Mellitus
II. Morbid Obesity
Narrative Conclusion
The unavailability of an ambulance to convey Nicola to hospital for necessary emergency treatment for undiagnosed type 2 diabetes mellitus resulting in a terminal cardiac event. This being a preventable death. | CIRCUMSTANCES OF DEATH
On 07 October 2024 I commenced an investigation into the death of Nicola Emma OWENS aged 40. The investigation concluded at the end of the inquest on 30 January 2025. The conclusion of the inquest was that:
Nicola Emma Owens was a 40 year old lady who had numerous co-morbidities, including obesity and a recent history of vomiting and diarrhoea. At approximately 14:00 hours on 4 October 2024 Nicola suffered a collapse whilst at work. She felt generally unwell but was talking. Five 999 calls were made to North-West Ambulance Service requesting their attendance. Paramedics arrived at 21:50 hours, by which time Nicola had deteriorated. She was placed in the ambulance where she proceeded to suffer a cardiac arrest at 22:40 hours. Nicola was then conveyed to the Royal Liverpool University Hospital at 22:49 hours having ongoing cardiopulmonary resuscitation (CPR), despite active treatment Nicola was pronounced deceased at 00:25 hours on 5 October 2024. The post mortem examination found Nicola died as a result of hyperosmolar hyperglycaemic state (HHS) caused by undiagnosed type 2 diabetes mellitus. HHS is a life-threatening complication of diabetes and occurs when the blood glucose (sugar) levels are too high for a long period leading to severe complications, including hyperkalaemia. HHS is a medical emergency and without treatment, it carries a high risk of mortality. Nicola did not appear to be critically unwell following her collapse but became progressively more unwell whilst waiting 7 hours and 28 minutes for an ambulance to arrive. From the evidence heard it is more likely than not, had Nicola been conveyed to hospital earlier the potassium salt levels could have been reversed and she would have survived. High potassium salt in the blood leads to cardiac arrhythmias and is treatable and reversible on most occasions. The cause for the delay in an ambulance attending to Nicola was due to the unavailability of ambulances at that time. This delay being significantly contributed to by the handover delays�across��� numerous hospitals across the North-West. A significant�factor contributing to the handover delays in the Royal Liverpool University hospital was a backlog of patients who were fit for discharge but awaiting social care packages. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
1. [REDACTED] (mother)
2. [REDACTED] (brother)
3.�North-West Ambulance Service
I have also sent it to
1.� The Royal Liverpool University Hospital
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. They may send a copy of this report to any person who they believe may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Emergency services related deaths (2019 onwards) | Department of Health and Social Care | NHS England & NHS Improvement |
03/12/2024 | 2025-0047 | Paul Gobell | Nottingham City and Nottinghamshire | 1��������� Ministry of Justice � MOJ
2���������HM Inspectorate of Prisons
3���������Chief Coroners Office for PFD�s | On 18 November 2021 I commenced an investigation into the death of Paul Martin GOBELL aged 59. The investigation concluded at the end of the inquest on 18 November 2024. The conclusion of the inquest was that:
See attached | See attached | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
Practice Plus Group LIMITED
[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. | State Custody related deaths | Ministry of Justice | HM Inspectorate of Prisons |
02/01/2025 | 2025-0001 | Gemma Marshall | West Yorkshire (Western) | 1��������� NHS England
2���������The Royal College of Radiologists | On 27.03.24� I commenced an investigation into the death of Gemma Suzanne Marshall (Female) (DoB 27.07.22) aged 46. Ms Marshall died on 15.03.24 at Huddersfield Royal Infirmary. The investigation concluded at the end of the inquest on 18.12.24.� The conclusion of the inquest was in narrative form:
Gemma Marshall died on 15.03.24 at the Huddersfield Royal Infirmary from the consequences of her gastric band slipping and causing her stomach to twist and suffer a haemorrhagic infarction. The infarction caused a build-up of blood-stained fluid in her peritoneum which stimulated her vagus nerve which then caused an arrhythmia in her heart. She then collapsed in the shower and could not be resuscitated. An outsourced CT scan failed to advise that the gastric band had slipped and this contributed to a failure to refer Gemma to bariatric specialists who could have intervened such that she might have lived. This failure represents neglect in the care that Gemma received. | Ms Marshall had private surgery for the fitting of a gastric band on 17.11.20. On 13.03.24 she attended the hospital with black vomiting and lower abdominal pain. She collapsed in the shower in hospital on 15.03.24 and did not recover. A postmortem found that the gastric band had �slipped� and that this was a causative factor in her death. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
�
[REDACTED]�
[REDACTED]�
Calderdale and Huddersfield NHS Foundation Trust
I have also sent it to
[REDACTED] (Trust Legal Representative)
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 | NHS England | Royal College of Radiologists |
13/12/2024 | 2024-0687 | Susan Evans | Hampshire, Portsmouth and Southampton | 1��������� Portsmouth Hospital NHS Trust | On 15 August 2023 I commenced an investigation into the death of Susan EVANS aged 55. The investigation concluded at the end of the inquest on 22 November 2024. The conclusion of the inquest was that:
�On 11 July 2023, Susan Evans underwent elective Roux-en-Y gastric bypass surgery. The surgery went to plan and appropriate measures were taken to avoid the possibility of an anastomotic leak, a rare but recognised complication of gastric bypass surgery. Initially, Ms Evans recovered well, but she experienced abdominal pain in the early hours of 13 July 2023. It is likely that this was due to an anastomotic leak. 13 July 2023 was the first day of a junior doctors� strike. Unrelated to this, the hospital only had the equivalent of one full time specialist bariatric nurse, who was not on duty. Contrary to Queen Alexandra hospital�s written policy for gastric bypass patients, Ms Evans was not seen by a member of the specialist bariatric team on 13 July 2023 and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak. The hospital at night nursing team, who administered pain relief, were unaware of the latter requirement.
In addition, Ms Evans not seen by a member of the bariatric team or any doctor prior to her discharge from hospital on the morning of 13 July 2023. Ms Evans was still in a degree of pain when she left hospital. She was re-admitted to hospital on 15 July 2023. By this point she was extremely unwell with abdominal sepsis from an anastomotic leak. She underwent remedial surgery on 15 July 2023 and a further operation was required on 25 July 2023. Despite appropriate medical care following her re-admission, her condition deteriorated, and she died at Queen Alexandra Hospital on 12 August 2023. It is likely that, if she had been seen by a member of the bariatric team on 13 July 2023, she would have been kept in hospital and would have been operated upon sooner. The failures identified contributed more than minimally to her death.� | See Narrative Conclusion above | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
[REDACTED]�
[REDACTED]
I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it.
I may also send a copy of your response to any person who I believe may find it useful or of interest.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. | Hospital Death (Clinical Procedures and medical management) related deaths | Portsmouth Hospital NHS Trust |
13/01/2025 | 2025-0020 | Diane Poole | Liverpool and Wirral | 1��������� Victoria Residential Home, Victoria House | On 26 September 2024 I commenced an investigation into the death of Diane POOLE aged 83. The investigation concluded at the end of the inquest on 13 January 2025. The conclusion of the inquest was that:
Diane Poole died from an Accidental death | On the 31st August 2024 Diane Poole along with another resident left Victoria House Care Home through a faulty emergency escape door. The door was defective and the alarm did not sound. Staff in the residential home were unaware that Diane Poole was missing for three hours. Diane Poole was found following an unwitnessed fall on Steel Street, Wallasey. She was taken to the trauma centre at Aintree University Hospital where she was treated for head and facial fractures. She was discharged from Aintree University Hospital on the 17th September 2024 to Acorn House Residential Home. She died on 23rd September 2024. It is found that the fall and injuries more than minimally contributed to her death. It is unclear as to whether the fall would have occurred had she been noticed as missing earlier. | 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
CQC
Care Quality Commission,
City Gate
Gallowgate
Newcastle upon Tyne
Tyne and Wear
NE1 4PA
[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. They may send a copy of this report to any person who they believes may find it useful or of interest.
You may make 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 | Victoria Residential Home |
13/01/2025 | 2025-0025 | June Liddell | West Sussex, Brighton and Hove | 1����������� LivaNova UK Limited | On 27 April 2023 I commenced an investigation into the death of June LIDDELL aged 68. The investigation concluded at the end of the inquest on 07 January 2025. The conclusion of the inquest was that:
June Liddell died on 1 April 2023 at Eastbourne General Hospital, Kings Drive, Eastbourne, East Sussex from a hypoxic brain injury which she sustained during surgery on her aorta at the Royal Sussex County Hospital, Eastern Road, Brighton on 21 March 2023. During surgery the heart lung bypass machine�s automated electronic remote clamp had a rare malfunction which caused it to close unexpectedly ceasing circulation of oxygenated blood to Mrs Liddell. The cause of the cessation was not identified before the injury had been sustained. | Mrs Liddell underwent cardiac surgery on 21 March 2023 which required her to be placed on a heart lung bypass machine. The machine used was an SP5 sold in the UK by LivaNova UK Limited.
At the point in the procedure where preparations were being undertaken to take Mrs Liddell off bypass by warming her blood and increasing the flow back to Mrs Liddell the SP5 did not generate any forward flow. The Perfusionist noted that the touchscreen control panel stopped showing the icons for the opening and closure of the automated Electronic Remote Clamp �ERC�. The Perfusionist considered that the failure could be caused by occlusion of one of the lines in the circuit for bypass but did not manually check the ERC.
The SP5 system generated an error message but then also generated a number of other error messages which forced the message to be moved down the list so that it may not have been visible on the screen as there is only room for 4 error messages at any one time.
The error message which the SP5 log shows as being generated at that time was �Arterial clamp is defective�.
The SP5 machine and ERC in this case had been maintained in accordance with the Manufacturer�s recommended maintenance schedule. I heard that this maintenance does not include an inspection of the ERC itself beyond a check that it is functioning at the time of the inspection. I heard that the likely cause of the malfunction of the ERC in this case was water ingress and wear and tear. The machine which was within its service life. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
The family of Mrs Liddell
MRHA (Medicines and Healthcare Products Regulatory Agency)
University Hospitals Sussex NHS Foundation Trust
I have also sent it to the Society of Clinical Perfusion Scientists of Great Britain & Ireland 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. | Product related deaths | LivaNova UK Limited |
07/07/2023 | 2023-0233 | David Lyth | Cheshire | 3D Trans
Health and Safety Executive | On 10 December 2021 I commenced an investigation into the death of David Alan LYTH aged 45. The investigation concluded at the end of the inquest on 27 June 2023. The conclusion of the inquest was that: � On 30 November 2021 at 3D Trans Shell Green Industrial Estate, Widnes, David Alan Lyth became trapped between two trailers resulting in asphyxia. � From the evidence presented the rollaway could only have occurred from neither the unit and the trailer brake not being applied. | On the 30th November 2021 David Lyth had been working for 3D Trans Limited through a driving agency. That day he had complained of an issue with the air cables on his trailer and had been advised to collect a new trailer from the 3D Trans Limited yard. As he coupled up to a new trailer, the trailer started to roll back and he put his arms out to stop it and became trapped between two HGV trailers. When he was found, he was unresponsive and was taken to Whiston Hospital where his death was confirmed. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
[REDACTED]
3D Trans
[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. | Accident at Work and health and Safety related deaths
This report is being sent to: 3D Trans, Health and Safety Executive | |
06/02/2024 | 2024-0067 | O�Shea Dover | North London | AACE Association Ambulance Chief Executives. �
Department of Health and Social Care, 33 Victoria Street, London SW1H 0EU | On the 27th May 2022 I opened an investigation touching the death of O�Shea Medad Dover who was 1 month old when he died. I opened an inquest on the 26th of September 2022, the inquest concluded on the 1st of February 2023. The conclusion of the inquest was the following narrative.
[REDACTED] was 30 weeks pregnant when she experienced abdominal pain and called emergency services. The call was wrongly categorised so paramedics arrived 44 minutes later than should have been the case. Midwifery advice was for the paramedics to bring [REDACTED] to hospital because pre-term deliveries require full obstetric and neonatal support. They did not follow this advice for three reasons�
�
They thought [REDACTED] was soon to deliver � a conclusion they�d be less likely to have reached had the call been correctly categorised and they�d been with her 44 minutes earlier;
Extrication from the property was challenging.
LAS guidance told them not to extricate if delivery is thought to be imminent.
�
Recognising the seriousness of the situation two midwifes came to [REDACTED]. They deemed her presentation to be more in keeping with placental abruption than imminent delivery and assisted paramedics in extrication [REDACTED] and taking her to hospital at 22.30. At 22.44, there was no foetal heart rate. At 23.04 O�Shea was delivered, resuscitation was started and caused a return of spontaneous circulation at 23.12. Given these things, it is likely O�Shea was subjected to acute severe hypoxia between 22.14 and 22.19. If the call to emergency services had been correctly categorised, [REDACTED] would have probably been in hospital by 20.57, Hme enough for CTG monitoring to recognise foetal distress prior to the hypoxia at 22.14 which would have prompted emergency caesarian. Had this happened it�s likely O�Shea would have survived. | As set out in the above narrative. Since O�Shea�s death London Ambulance Service has added �JRCALC Plus� guidance stating where delivery is not progressing the patient should be conveyed to a hospital with obstetric support. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;-
The Family
�
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. | Child Death (from 2015) | Emergency services related deaths (2019 onwards)
This report is being sent to: Association Ambulance Chief Executives | Department of Health and Social Care | |
18/07/2023 | 2023-0249 | Ronald Ashdown | Essex | Acting CEO, Mid and South Essex NHS Foundation Trust�[REDACTED] , Level G, Basildon Hospital, Nethermayne, Basildon, SS16 5NL | On 3rd September 2021 I commenced an investigation into the death of Ronald Scott Ashdown, aged 55 years. The investigation concluded at the end of the inquest on the 1st June 2023. The conclusion of the inquest was one of natural causes in the context of an expanded narrative conclusion. | Ronald Scott Ashdown (RA) died on the 15th August 2021 at Basildon University Hospital, Nethermayne, Basildon, Essex from complications arising from the severe disability sustained following a cardiac arrest and subsequent significant hypoxic brain injury in 2013. �
The deceased died from natural causes (aspiration pneumonia) on a background of long-term and severely incapacitating disability following a hypoxic brain injury consequent upon a cardiac arrest sustained whilst asleep in bed in 2013. Over the subsequent years the deceased benefitted from the continued and committed advocacy of his daughter to ensure maximal support for her father from the Coach House Nursing Home where he was a resident and also during his frequent periods as an in-patient at Basildon University Hospital. �
Prior to his death RA had been admitted to Basildon Hospital on 6th July 2021 with shortness of breath, cough and fever having been noted to tachypnoeic and desaturating at the Nursing Home. He was treated with antibiotics for aspiration pneumonia, a frequently occurring complication of his long-term condition. RA was vulnerable to recurrent infections at the site of the PEG; he had two feeding tubes in situ: a PEG & PEJ. After extensive clinical review, on the 21st July the (buried) PEJ was surgically removed under local anaesthetic and feeding resumed via Jejunal extension placed through the old PEG from 28th July.� RA was discharged back to the care of the Nursing Home when he was deemed clinically stable on 2nd August 2021 but was readmitted to Basildon Hospital on 12th August after dislodging the Jejunostomy tube; he passed way three days later on 15th August. | I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
�
[REDACTED] daughter of the deceased;
[REDACTED] and Thurrock Local Authority Safeguarding and�[REDACTED], Business Manager of Thurrock Safeguarding Adults Board;
�
CQC responsible for MSE and Basildon Hospital.
I am also under a duty to send the Chief Coroner a copy of your response.
�
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make 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 Foundation Trust | |
31/03/2023 | 2023-0112 | Veronica Jenkins | Surrey | Acting Chief Executive South East Coast Ambulance Service 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 Mrs Jenkins was opened on 7 June 2022. The inquest was resumed and concluded on 30 January 2023.
�
The medical cause of Mrs Jenkins� death was:
�
1a. Small Bowel Ischaemia
1b. Intra-Abdominal Adhesions due to Previous Surgery
�
The inquest concluded with a short narrative conclusion of �Recognised
Complication of Surgery�. | Mrs Jenkins was a 72 year old woman with a diagnosis of bowel cancer for which she underwent a surgical resection in 2016. Thereafter, she had a further procedure to reverse her ileostomy in 2017. In 2022 the cancer spread to her lungs and it was planned for her to commence chemotherapy in May 2022.
However, late at night on 10 May 2022 Mrs Jenkins developed sudden onset chest pain and was taken to St. Peter�s Hospital, Chertsey, by ambulance. En route to the hospital at 00:39 on 11 May 2022 she suffered a cardiac arrest and was successfully resuscitated at 00:56. She suffered a further cardiac arrest at 01:18 shortly after the ambulance arrived at the hospital and efforts to resuscitate her were not successful and she died at the hospital on 11 May 2022.
The cardiac arrest had resulted from Small Bowel Ischaemia which was due to Intra-Abdominal Adhesions, which is a recognized complication of the previous abdominal surgery she had undergone.
The court found that there was a delay in the ambulance response for Mrs Jenkins on 10 May 2022 but that the delay did not materially contribute to her death.
With respect to the delay, the court heard that the 999 call for an ambulance was made at 23:11 on 10 May 2022 and was correctly triaged at 23:14 as a Category 2 call. Category 2 calls have a mean response time of 18 minutes according to the national framework governing ambulance response times. However, an ambulance did not arrive to Mrs Jenkins� address until 23:47, which is a response time of 33 minutes, and therefore a delay of 15 minutes.
The court heard evidence from [REDACTED], Operations Unit Manager at South East Coast Ambulance Service (SECAMBS), that on 10 May 2022 the service was experiencing exceptional demand and the response times for all categories of 999 calls were experiencing significant delays with an increased potential for patient safety and care to be compromised.
[REDACTED] gave evidence that the delays were due to a deficit in the amount of operational hours that SECAMBS was able to provide on 10 May 2022. The overall required operational hours across the region were 9,652 and on 10 May 2022 only 9,064 were provided, which is a deficit of � 6.1%. With respect to the Chertsey area particularly, the required operational hours were 822.00 and only 751.75 were provided, which is a deficit of -8.5%.
[REDACTED] gave evidence that the deficit was due to two factors
1.���� A lack of availability of staff due to a combination of sickness, covid related absence and annual leave; and
2.���� Handover delays at hospitals leading to a loss of 191.04 operational hours across the region on 10 May 2022.
Having heard the evidence, the court was not reassured that these factors would not reoccur in the future, as such giving rise to the risk of future deaths. | COPIES
I have sent a copy of this report to the following:
1.���� Chief Coroner
Mrs Jenkins� family | Emergency services related deaths (2019 onwards)
This report is being sent to: South East Coast Ambulance Service | Department of Health and Social Care |
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