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Grant Nicholas LOWRY · Prevention of Future Deaths report View report

30 Mar 2026 Teesside and Hartlepool C. Bailey

Grant Nicholas LOWRY left home on 1 June 2022 after sending a text indicating suicidal intent and was found deceased in the early hours of 3 June 2022 following an uncoordinated search. Concerns included inaccurate and incomplete recording of search information, communication failures, delayed requests for additional search resources, and inadequate operational equipment for one officer. The inquest found that missed opportunities in mental health care and the search deficiencies contributed to the circumstances surrounding his death.

Philip Laurence Justin MALONE · Prevention of Future Deaths report View report

23 Nov 2023 Birmingham and Solihull J. Bennett

Philip Laurence Justin Malone, who had treatment-resistant schizophrenia and had deteriorated significantly in late June 2023, was found deceased in his supported accommodation on 3 July 2023. The inquest concluded that his death was the consequence of suicide. The principal concern was inadequate psychiatric bed capacity in Birmingham and Solihull, after clinicians sought to admit him but no inpatient bed was available, creating an ongoing risk of future deaths.

Huseyin Hasan Erdogan · Prevention of Future Deaths report View report

17 Feb 2015 North London J. Taylor

Huseyin Hasan Erdogan hanged himself on 4 June 2014 and died on 13 June 2014 from cerebral hypoxia resulting directly from the hanging. The inquest identified a failure by mental health practitioners to conduct and act upon a fully informed assessment of his mental state, contributing to no steps being taken to prevent the hanging. Concerns were also raised that action-plan steps intended to address recommendations had not been completed by the inquest and that further deaths might not be prevented without their completion.

James Alan Tice · Prevention of Future Deaths report View report

5 Sep 2022 Manchester North C. McKenna

James Alan Tice, who had recurrent depressive disorder with anxiety features, took his own life at home on 28 April 2022 while awaiting an informal admission to an older adult mental health ward. The report identifies concerns about the availability of beds for such admissions and psychotherapy services for older adults whose needs exceed community provision.

Brandon William Turner · Prevention of Future Deaths report View report

5 Sep 2024 Cornwall and Isles of Scilly A. Cox

Brandon William Turner, who had diagnoses of PTSD and autism, died from suicide on 21 June 2023 at age 21; the recorded cause of death was asphyxia from fatal pressure on the neck. He had been referred to a community mental health therapy pathway, but treatment had not commenced before his death. Concerns included staffing shortages, the absence in Cornwall of a therapeutic alternative to hospital detention for people with complex PTSD/EUPD in crisis, and a lengthy autism assessment waiting list.

Mr. Rohan Fitzsimons · Prevention of Future Deaths report View report

7 Aug 2016 Avon P. Harrowing

Mr. Rohan Fitzsimons, who had been detained under the Mental Health Act and was receiving inpatient psychiatric care, died after jumping from Clifton Suspension Bridge while on unescorted leave on 25 November 2015. The principal concern was that a necessary Mental Health Act Assessment was delayed for four days because no inpatient bed was available, with evidence that this commonly occurred and that assessments were not carried out until a bed became available.

John Paul Derwent · Prevention of Future Deaths report View report

4 Jun 2018 Manchester South A. Mutch

John Paul Derwent was referred for cognitive behavioural therapy while the waiting time was 12 months against a six-week target. He expressed suicidal ideation, was admitted and later discharged into the community; on 13 November 2017 he was found suspended from a ligature at home. The report raised concerns about insufficient CBT capacity, the substantial waiting list and escalation mechanisms that did not allow early action.

Jason Derek Vaughan · Prevention of Future Deaths report View report

11 Mar 2016 South Yorkshire (Eastern) M. Beresford

Jason Derek Vaughan died by suicide by hanging at his home on 23 September 2015. The principal concerns were limitations in the IAPT electronic clinical records, a risk assessment tool that did not capture deterioration below its highest-risk level, and insufficient recognition of factors associated with suicide among middle-aged men and socio-economic groups.

Julie Sheila Beasley · Prevention of Future Deaths report View report

28 May 2025 Essex S. Hayes

Julie Sheila Beasley was found deceased at home on 16 March 2023 and died from multiple drug misuse involving a fatal amount of morphine and concomitant prescribed medications. She had deteriorating mental health, increasing suicidal thoughts and plans, and repeatedly requested mental health assessment and a medication review. The report identifies failures to complete required assessments and medication review, inadequate communication and record keeping, and insufficient exploration of information she sought to share about her risks.

Charlotte Emily BEVAN and Zaani Bevan Malbrouck · Prevention of Future Deaths report View report

27 Oct 2015 Avon M. Voisin

Charlotte Emily Bevan, who had schizophrenia and an undiagnosed psychotic relapse following childbirth, left hospital with her four-day-old daughter Zaani and went to the Avon Gorge cliff top; both died from injuries. The inquest identified failures including the absence of multidisciplinary care planning, insufficient psychiatric involvement, and failures to diagnose and manage Charlotte’s relapse.

Max TURBUTT · Prevention of Future Deaths report View report

18 Oct 2022 Inner North London M. Hessel

Max Turbutt had experienced mental ill health for several years and had been supported by Kent County Council services as a care leaver. The report states that he died by suicide, with the medical cause of death recorded as hanging. Concerns were raised that attempts by Max and his father to contact his personal adviser were unsuccessful, with no phone redirect or email out-of-office message, and that a crisis number led only to an answerphone.

Louise Sharon Henry · Prevention of Future Deaths report View report

16 Oct 2015 Derby and Derbyshire S. Cartwright

Louise Sharon Henry was found deceased at home on 1 April 2013 after consuming a substantial amount of amphetamine and ibuprofen while experiencing a deterioration in her mental state, including psychotic symptoms and hallucinations. The report identified concerns about her discharge from mental health services, including failures to communicate relapse triggers and a clear contingency plan, lack of reassessment after reports of deterioration, and ambiguity between agencies about care-coordination roles and procedures.

Iain Neil MACINNES · Prevention of Future Deaths report View report

24 Sep 2019 Milton Keynes T. Osborne

Iain Neil MACINNES was found hanging at his home in Milton Keynes on 17 January 2019, after his mental health had deteriorated during December 2018. The report identified concerns that his family were not informed about his deterioration or transfer to the Acute Home Treatment Team, and that there was a failure to recognise the extent of his deterioration, resulting in lost opportunities for hospital admission.

Neil Stephen David SWAISLAND · Prevention of Future Deaths report View report

12 Dec 2018 Milton Keynes T. Osborne

Neil Stephen David SWAISLAND died after jumping from the top floor of a multi-storey car park in Milton Keynes on 14 July 2018. Evidence was heard that funding for MIND counselling services had been withdrawn by the Council and the CCG, raising concern that vulnerable people would be at increased risk of self-harm and suicide and that this could result in further suicide deaths.

Aaron Michael VRANAS · Prevention of Future Deaths report View report

11 Aug 2014 Bedfordshire and Luton T. Osborne

Aaron Michael VRANAS died after falling from a tenth-floor window at Bury Court, Church Lane, Bedford, on 13 April 2014, sustaining fatal multiple injuries. A concern was raised that treatment for psychiatric illness and ADHD was provided at two different hospitals many miles apart, making the patient difficult to manage.

David Moran · Prevention of Future Deaths report View report

6 Jan 2017 Cheshire N. Rheinberg

David Moran, who had bipolar affective disorder and a history including suicide attempt and suicidal ideation, died after taking a fatal overdose of metformin; the inquest could not determine his intention. Concerns included imprecise referral-priority guidance, the absence of a default urgent response when screening was not possible or the situation was ambiguous, and ineffective communication between administrative and clinical staff.

Sarah Louise Healey · Prevention of Future Deaths report View report

11 Oct 2025 West Sussex, Brighton and Hove J. Turner

Sarah Louise Healey was admitted to hospital on 4 May 2024 with severe malnutrition and complex infections after longstanding mental health difficulties and a highly restricted diet. She deteriorated and died on 1 August 2024 from respiratory failure secondary to pleural effusions, hypoalbuminaemia and malnutrition. The principal concerns were inadequate, inconsistent and insufficiently joined-up mental health care, information sharing and collaboration, particularly for patients with physical health issues, neurodiversity or difficulty attending in-person appointments.

Andrew John Hughes · Prevention of Future Deaths report View report

5 Dec 2025 Manchester South A. Mutch

Andrew John Hughes was found deceased at his home after concerns about his wellbeing and unsuccessful attempts to contact him. The inquest concluded that he died by suicide, with the medical cause recorded as hanging. The principal concern was a lack of clarity about how people raising urgent mental-health concerns could be directed to mental-health services and what emergency response those services could provide.

Henry Marsh · Prevention of Future Deaths report View report

2 Jul 2014 North London A. Walker

Henry Marsh had multiple diagnoses and was under the care of the Home Treatment Team when he failed to attend a psychology appointment and was found unresponsive at home. The principal concern was that the Home Treatment Team had too many patients to manage effectively, making multidisciplinary meetings difficult; the inquest recorded suicide and polydrug intoxication as the medical cause of death.

Martin COLLINS · Prevention of Future Deaths report View report

17 Sep 2025 Suffolk P. Taheri

Martin Collins, a 66-year-old male serving a prison sentence, died by suicide after being found suspended in his cell at HMP Highpoint on 25 November 2023. The report raises concerns that the prison telephone system could not automatically identify unusually high call volumes and alert staff or healthcare, potentially missing opportunities to identify risk triggers and intervene.