Delwyn PREECE · Prevention of Future Deaths report

On 1 September 2025 I commenced an investigation into the death of Delwyn PREECE. The investigation concluded at the end of the inquest .

The conclusion of the inquest was: Suicide.

The cause of death was :

1a Hypoxic brain injury

1b Hanging

This case relates to the death of a 64 year old man who passed away at Rotherham Hospital on the 19th August 2025, as a result of a hypoxic brain injury following deliberate self suspension by ligature in the grounds of Swallownest Court, an acute mental health hospital in Rotherham.

Mr Preece was admitted as an informal patient on the 2nd December 2024 due to mixed anxiety and depression with associated suicidal ideation. During his admission, there were three recorded incidents where items of clothing were used to fashion ligatures.

Over time Delwyn improved, and he was permitted periods of unescorted leave from the ward. On the 10th August 2025, Delwyn left the ward in the morning, returning following prompting by staff at lunchtime, then left again and returned later that afternoon.

At approximately 18:20 hours, Delwyn left the ward again. At 19:05 hours, the ward received contact from the police after a member of the public reported finding Delwyn suspended ████████ ████████ Delwyn was transferred to the Rotherham District General Hospital where he died nine days later.

There was evidence of poor documentation throughout the admission. On a number of occasions, including the 10th August 2025, there is no record to demonstrate that a mental state examination was undertaken or documented prior to leave from the ward being granted.

1. There were consistent and repeated incidents (13 incidents in 6 days) where leave from the ward was granted without any documented mental state examination or risk assessment being undertaken prior to the patient being permitted to leave the ward.

2. There was poor documentation throughout the medical records with entries lacking detail, being added retrospectively (up to two days later) without any explanation or referencing the retrospective nature of the entry.

3. The Patient Safety Incident Investigation authors were unfamiliar with the medical records system which lead to the retrospective entries not being identified correctly, therefore the investigation did not make any finding. However, with more understanding, it is likely the retrospective entries in the medical records who have been identified and their relevance realised which would have altered the content and findings of the report.