Name not published · Prevention of Future Deaths report

On 21 October 2025 I commenced an investigation into the death of ████████
████████. The investigation concluded at the end of the inquest on 2 April 2026.

████████ had no known mental ill-health and was an experienced Operational Department Practitioner based at Birmingham Children's Hospital. During his shift on 07/10/25 he was informed of a conduct issue. A risk assessment noted he could travel home safely and having family at home was a supportive factor. He was informed he should not come into work the following day whilst a decision was made about an investigation, and that he would be telephoned the following morning with an update. The following morning, on 08/10 around 5:30-6:00am, contrary to instructions, he attended the hospital and accessed a secure drug store and removed anaesthetic medication and intravenous cannula equipment. This was the last known sighting. From 8:45am his employer attempted to contact him via telephone without success to inform him he was to be suspended pending an investigation. Concerns were escalated around 1:30pm that he was a missing person. When it was revealed he had accessed the hospital, a search was undertaken and he was found in the afternoon deceased in a bedroom in on-call accommodation having deliberately injected himself with the anaesthetic. The medical cause of death was confirmed at post-mortem as 1a. Self-injection of ████████
████████. The conclusion was that death was the consequence of suicide.

1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks.