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Joy Burgess · Prevention of Future Deaths report View report

4 Feb 2022 Manchester South C. Morris

Joy Burgess died by suicide on 9 June 2021 as a consequence of multiple injuries. She had complex mental health difficulties, was experiencing deteriorating mental health and thoughts of self-harm, and had left hospital because she found the ward environment busy and extremely noisy. The concerns identified were that mental health wards could be unsuitable for recovery and that patients experienced lengthy waits for psychological therapies.

Daniel HALL · Prevention of Future Deaths report View report

10 Nov 2021 South Wales Central S. Richards

Daniel Hall was a 20-year-old student at the University of South Wales who expressed suicidal thoughts on two occasions while awaiting mental health support. He died at his student accommodation on 9 December 2019, and the coroner’s short-form conclusion was suicide. The principal concern was lengthy delays in accessing mental health support despite expressed suicidal ideation and known autism spectrum disorder, together with a lack of safeguarding.

Jason Ricardo White · Prevention of Future Deaths report View report

19 Dec 2025 South Yorkshire (Eastern) N. Mundy

Jason Ricardo White died on 10 December 2024; the cause of death is redacted in the supplied text, and the inquest conclusion was suicide. The principal concerns were the abrupt cessation of olanzapine, failure to follow the planned daily monitoring, and the resulting risk of relapse and serious deterioration in mental health.

Siwan Llio SMITH · Prevention of Future Deaths report View report

14 Sep 2021 Gwent C. Saunders

Siwan Smith had a long-standing history of anxiety and depression, which worsened during the Covid-19 pandemic, and she died by hanging at home on 23 November 2020. The report raised concern that, when she sought an earlier appointment and was distressed, reception staff did not identify whether she required urgent mental health support or arrange a call from a clinically trained person.

Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report View report

16 Dec 2024 West Sussex, Brighton and Hove P. Schofield

Matthew Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health assessment.

Patricia Ferguson · Prevention of Future Deaths report View report

23 Apr 2020 Nottinghamshire G. Clow

Patricia Ferguson had significant mental ill health and received secondary mental health services before her death by suicide. Clinicians considered that direct work with a clinical psychologist would benefit her, but no clinical psychologist was available; the report identified limited clinical psychology provision in community mental health teams as an ongoing risk of preventable future deaths.

Isobel Lilian Stapleton · Prevention of Future Deaths report View report

25 Jun 2024 South Wales Central D. Regan

Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.

Shirley Alice Moloney · Prevention of Future Deaths report View report

9 Jun 2022 East London N. Persaud

Shirley Alice Moloney, who had longstanding paranoid schizophrenia and severe frailty, was found unresponsive at her care home on 10 December 2020 after suffering three vomits the previous day. The report states that it was likely she died from aspiration pneumonia and that the death was from natural causes. Concerns included the deterioration of her mental health and the lack of community mental health team care in the last nine months of her life, alongside wider concerns about access to older adult psychiatry for care-home residents.

Stephen Anthony Kennedy · Prevention of Future Deaths report View report

7 Feb 2019 Birmingham and Solihull L. Hunt

Stephen Anthony Kennedy had a history of emotional unstable personality disorder, depression and frequent self-harm, and his condition deteriorated during 2018. He was found hanging at his home on 08/10/18 and was declared deceased. Concerns included that psychological therapy was unavailable because of service structures and long waiting lists, and that a lack of acute inpatient beds contributed to further episodes of self-harm and suicide attempts.

Joanna Chamberlain · Prevention of Future Deaths report View report

10 Nov 2025 West Sussex, Brighton and Hove J. Turner

Joanna Chamberlain took her own life at home on 23 January 2025 after a recent overdose, other self-harm incidents and an assessment that she was at moderate risk. The report raises concerns about the lack of safe, supportive spaces for people needing more support than home treatment teams can provide, and about clinicians seeking and including family or other relevant input when care plans depend on protective factors.

Mena Tekloe Marim Teferi · Prevention of Future Deaths report View report

7 Jun 2022 West London L. Brown

Mena Tekloe Marim Teferi died by suicide at home on 10 October 2021, after being referred to a mental health service but not seen or contacted before her death. The service was described as critically under-resourced, with demand substantially exceeding capacity and resulting in failures to meet service obligations.

Alice, Sarah, Dearden (Alice) · Prevention of Future Deaths report View report

29 Apr 2026 Wiltshire and Swindon N. Rheinberg

Alice had mental health difficulties associated with anorexia nervosa and emotionally unstable personality disorder, including acts of self-harm and overdoses. She died by suicide at age 19. Evidence suggested that a strict commissioning cut-off at age 18 could adversely affect mental health by making transitions from child to adult mental health services insufficiently gradual.

Margaret Elizabeth Conway · Prevention of Future Deaths report View report

3 May 2017 West Yorkshire Eastern D. Hinchliff

Margaret Elizabeth Conway, aged 68, was admitted to Pinderfields Hospital with diarrhoea, acute kidney injury and pancolitis after being transferred from Fieldhead Hospital. She suffered a cardiac arrest and died at 0110 hours on 3 September 2016; the inquest recorded natural causes, including acute myocardial infarction and acute severe colitis. The substantive concerns related to the challenges of transferring and caring for patients with both serious mental and physical health problems across geographically and operationally separate services.

Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report View report

8 Sep 2019 East Sussex A. Craze

Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.

Robert Leighton SMITH · Prevention of Future Deaths report View report

10 Apr 2025 Manchester South A. Mutch

Robert Leighton Smith was found unresponsive at home on 25 October 2024 while prescribed high levels of painkillers; toxicology found above-therapeutic levels of his prescribed medication, and the inquest concluded accidental death. He had been assessed as likely to benefit from Interpersonal Psychotherapy but had not started it because of a significant waiting list, with average waits of 12 months attributed to demand exceeding commissioned capacity.

Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report View report

16 Dec 2024 West Sussex, Brighton and Hove P. Schofield

Matthew Zak Sheldrick (Matty), who identified as non-binary, attended A&E in crisis on 3 November 2022 following deteriorating mental health and intense suicidal thoughts. After being assessed under the Mental Health Act and not detained, Matty left the hospital and was found suspended by a ligature in the hospital grounds. The report identified concerns including the lack of suitable inpatient beds, the unsuitability of A&E for neurodivergent patients, gaps in service provision, and shortcomings in the mental health assessment and discharge care planning.

Barry Marshall Fullarton · Prevention of Future Deaths report View report

17 May 2019 Liverpool and the Wirral A. Rebello

Barry Marshall Fullarton died on 17 December 2018 after intentionally falling from the balcony of his bedroom, while suffering from a reactive depressive illness following a stroke. The principal concern was that mental health assessments should account for how a disorder manifests over time, including the possibility that an afternoon assessment during improved mood may not reflect needs during morning low mood.

Hannah Dolly Kaur Bharaj · Prevention of Future Deaths report View report

24 Jul 2019 Manchester South A. Mutch

Hannah Dolly Kaur Bharaj had anorexia, depression and fluctuating suicidal ideation, and died at Salford Royal Hospital on 13 July 2018 from injuries sustained after jumping from a first-floor café. Concerns included inadequate communication and discharge planning, unsuitable placement and care coordination, incomplete sharing of clinical information, and the safety of the café balustrade and adjacent table.

Daniel Norman Hatchett · Prevention of Future Deaths report View report

4 Jul 2025 East London N. Persaud

Daniel Norman Hatchett had declining physical and mental health, including stress alongside chronic health conditions. In the early hours of 9 November 2024, he was found hanging at home and pronounced dead at the scene; the circumstances were deemed non-suspicious. The report identified missed opportunities for mental health follow-up and therapy, and concerns about chronic disease reviews not adequately addressing patients’ mental health, particularly where men may not disclose concerns without being asked directly.

Tania Louise JARMAN · Prevention of Future Deaths report View report

12 Mar 2026 Cheshire E. Wheeler

Tania Louise JARMAN died aged 54 on 27 February 2024 at Park House, a non-clinical crisis placement, after tying a ligature with the probable intention of ending her life. Her mental health had worsened before her death, and her admission removed her from protective factors including her mother and home. The principal concerns were the longstanding shortage of mental health beds and the risk that this could lead to an artificially elevated threshold for referrals, potentially denying beds to patients with a clinical need.