James APPLETON died on 17th July 2022 at his Nursing Home from an infection following two falls in March 2022 which both required surgery There was also a delay in reaching Mr TAYLOR as he had suspended himself behind the door and it could not be opened immediately His risk of suicide was insufficiently evaluated which meant that he was not observed as frequently as he should have been.ģ. Mr TAYLOR's mental health had declined following his admission to hospital but he had not been appropriately reassessed on the ward he was transferred to.Ģ. Although the following factors were not causative of death, they possibly contributed to Mr TAYLOR's death:ġ. Following being found he received treatment in hospital but did not survive. Mr TAYLOR had deliberately taken steps to end his life with the intention of doing so. He was admitted to a mental health ward on 2 November 2021 and found suspended behind the door of his room by a ligature on 3 November 2021. He was hearing voices telling him to kill himself and felt he could not keep himself safe if he was not in hospital. He attended Royal Blackburn hospital on 1 November 2021 following a deterioration in his mental health. Mr TAYLOR was diagnosed with psychosis in May 2021. Leighton Dale TAYLOR died on 10 November 2021 at Royal Blackburn Hospital, Blackburn. Sheila Ann GIBSON who suffered from co morbidities died on 21st July 2022 at Royal Preston Hospital from an infection following a witnessed fall on 7th July 2022 which required surgery undertaken on 9th July 2022 John Harris GORDON died on the 20th July 2022 at the Royal Blackburn Hospital, Blackburn, from sepsis of an unknown aetiology, probably contributed to by chronic intravenous drug abuse Amy ROWE died of a cardiac arrest, caused by an upper gastrointestinal bleed which was the result of years of abuse of anti-inflammatory medication, linked to an eating disorder.ĭied as a result of choking, contributed to by neglect.

The beverage report; by Derek Cooper