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Keith Andrew NOTTLE · Prevention of Future Deaths report View report

14 Jun 2022 Nottinghamshire G. Clow

Keith Andrew Nottle died on 5 July 2021 after taking an overdose of two prescribed medications, which the inquest concluded was an accident. Concerns included telephone triage practices that could bypass specialist mental health assessment, the apparent lack of care coordination, and unclear decision-making around his discharge and repeated re-referrals to mental health services.

Karen Jane Edgar · Prevention of Future Deaths report View report

16 Apr 2018 Cumbria D. Roberts

Karen Jane Edgar had emotional and behavioural difficulties and was referred to CAMHS in October 2015, aged 15. She received delayed and limited mental health support, including gaps in family therapy, individual therapy, risk reassessment and care planning, before she died after hanging herself on 8 April 2017. The report raised concerns about underfunded child and adolescent mental health services, delays in treatment and inadequate resources and care.

Matthew Christopher Dunham · Prevention of Future Deaths report View report

12 Sep 2013 Norfolk W. Armstrong

Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

Ben Alan SHIPLEY · Prevention of Future Deaths report View report

27 Apr 2023 West Yorkshire (Western) I. Pears

Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.

Valeria Munoz Biggs · Prevention of Future Deaths report View report

11 Feb 2021 Inner West London F. Wilcox

Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

Allan Michael WADDUP · Prevention of Future Deaths report View report

10 Aug 2022 North Northumberland A. Hetherington

Allan Michael WADDUP died in prison on 13 December 2019 after seeking mental health support. He had been referred and later self-referred, but was discharged without an assessment, was not assessed before his death, and concerns were raised about appointment notification, the Did Not Attend process, delays in triage, and the absence of weekend triage or urgent-assistance guidance on the prison kiosk.

Brian Goodman · Prevention of Future Deaths report View report

17 Apr 2019 Inner North London S. Bourke

Brian Goodman, who had a history of suicide attempts by hanging, was found hanging from the door-closing mechanism of his room on 9 November 2018. The concerns included that this mechanism was not changed after another ligature point had been removed and that the same type of mechanism continued to be used in One Support properties.

Mr Paul Timothy Dunne · Prevention of Future Deaths report View report

13 Mar 2025 South London A. Harris

Mr Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.

Saul Richard THOMAS · Prevention of Future Deaths report View report

21 Dec 2021 Worcestershire D. Reid

Saul Richard Thomas died in his cell at HMP Hewell on 19 May 2019 after being transferred there from HMP Birmingham, where he had expressed paranoid thoughts and was undergoing psychiatric assessment. The concerns included failures to open an ACCT document, communicate important mental-health information during the prison transfer, and adequately assess and manage his mental health at HMP Hewell; the inquest found that these failures probably or possibly caused or contributed to his death.

Kate Hedges · Prevention of Future Deaths report View report

3 May 2022 Manchester South C. Morris

Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.

Nicola Norman · Prevention of Future Deaths report View report

14 Mar 2023 Inner West London F. Wilcox

Nicola Norman died on 20 January 2020, aged 42, after being found dead hanging at her mother’s address. Before her death, she contacted the Single Point of Access while highly anxious, reported feeling a burden and later reported an overdose and cutting her wrists. The principal concerns were that these contacts were not routinely discussed with a supervising clinician, passed to a suitably qualified clinician for assessment, or notified to her GP and mental health services.

Corinne Haslam · Prevention of Future Deaths report View report

21 Jul 2023 Manchester South C. Morris

Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.

Andrew BOWLES · Prevention of Future Deaths report View report

31 Oct 2023 Birmingham and Solihull A. Samuel

Andrew BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.

John Paul Hurst · Prevention of Future Deaths report View report

23 Oct 2024 Sunderland D. Place

John Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.

Claire Louise Driver · Prevention of Future Deaths report View report

24 Mar 2025 South Yorkshire (Western) T. Rawden

Claire Louise Driver had a history of schizoaffective disorder and polysubstance misuse and was found in significant decomposition in a shallow stream on 14 September 2024 after being reported missing on 24 June 2024. The cause of death was unascertained. The inquest heard concerns about limited attempts to engage her while her mental health was deteriorating, liaison between police and mental health services, and staff training on substance misuse and mental health.

Craig David Royce · Prevention of Future Deaths report View report

20 Dec 2017 Essex C. Beasley-Murray

Craig Royce, who had a history of mental health problems and epilepsy, was found hanging in his prison cell on 24 December 2016. The report identified concerns that a referral to mental health services following an incident of self-harm was not made and that there was no robust documentary system for communicating such referrals. The inquest jury also considered that his risk of self-harm or suicide was not properly reviewed with appropriate precautions taken.

Sky Louise Rollings · Prevention of Future Deaths report View report

16 Oct 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Sky Louise Rollings was transferred from a child and adolescent mental health hospital to an adult mental health unit on 4 November 2019 and died at Royal Stoke University Hospital on 9 November 2019, following an incident at Harplands Hospital. The inquest heard concerns about differences between child and adult mental health care and the lack of inpatient provision for people aged 14 to 25, which was considered to create a risk of further deaths.

Michael Joseph HINDES · Prevention of Future Deaths report View report

20 Oct 2023 Inner North London M. Hassell

Michael Hindes died by suicide after calling 999 because he felt suicidal and being taken to St George’s Hospital for a half-hour mental health assessment before discharge. The principal concerns were that he was not referred to the crisis team despite a likely minimum one-week wait for community mental health follow-up, and that the assessing nurse did not try to persuade him to involve his family, who were unaware of his mental ill health until after his death.

Mark Alan Hughes · Prevention of Future Deaths report View report

4 Mar 2026 Manchester South B. Myers

Mark Alan Hughes, who had a history of anxiety and was assessed as at high risk of self-harm and suicide, died after taking codeine and morphine and stabbing himself during the night of 22–23 June 2025. The report raised concerns that urgent referrals from general practice could not be made directly to the Home Based Treatment Team in South Trafford, resulting in a delay over the weekend before assessment or onward referral could occur.

Robert Joseph DAY · Prevention of Future Deaths report View report

24 Mar 2026 Kent and Medway I. Potter

Robert Day died on 15 January 2025 after taking a significant overdose of prescription medication and refusing treatment after an ambulance and police response. The principal concern was the absence of national guidance for frontline emergency services dealing with complex, time-critical situations involving mental health concerns, which the report said risks the lives of others.