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Amy Jade BUTCHER · Prevention of Future Deaths report View report

26 Nov 2024 Suffolk N. Parsley

Amy Jade Butcher was declared deceased on 14 May 2023 after suspending herself with a ligature around her neck during a heightened anxiety crisis. The inquest identified concerns about a confusing, fragmented system for prescribing mental health medication, and about the decision not to prescribe Lorazepam despite its previous effectiveness for Amy.

Zoe Emma ZAREMBA · Prevention of Future Deaths report View report

25 Apr 2022 North Yorkshire and York including North Yorkshire Western District J. Broadbridge

Zoe Emma ZAREMBA, who had a history of repeated self-harm and suicide attempts, ingested an unknown quantity of a substance after going missing from home and was found unresponsive on 21 June 2020; her death was established as resulting from the ingestion. The report identified concerns about clinicians’ failure to understand and adapt care to her autism, the unsubstantiated attribution of Emotionally Unstable Personality Disorder, inadequate coordinated mental health support, and the absence of effective care planning and risk assessment.

Andrew Michael Horgan · Prevention of Future Deaths report View report

8 Apr 2014 Wiltshire and Swindon D. Ridley

Andrew Michael Horgan died on 16 September 2013 from acute cardiac failure following a Colchicine overdose, with coronary artery atherosclerosis, myocardial fibrosis and focal incomplete hepatic cirrhosis also identified. The principal concern was that hospital staff lacked a clear understanding of referral procedures for mental health assessment following discharge, creating a risk that similar communication failures could contribute to a future death.

Sandra Bodrožič’ · Prevention of Future Deaths report View report

24 Nov 2014 Inner North London M. Hassell

Sandra Bodrožič’ died after running to the attic, saying goodbye and jumping from a window, landing three storeys below. She had previously been detained under the Mental Health Act and treated in hospital and the community. The substantive concerns included delays in finding a hospital bed, arranging a Mental Health Act assessment, and the absence of clear urgency or timeframe protocols for such assessments.

Dominic Michael WHITE · Prevention of Future Deaths report View report

24 May 2017 Inner North London M. Hassell

Dominic White, who had bipolar affective disorder and psychosis, rapidly deteriorated over several days and was assessed as requiring detention under section 2 of the Mental Health Act. Before he could be conveyed to a mental health hospital, he left the emergency unit and was found the following day at an electricity substation with injuries consistent with a fall from height. The concerns included whether mental health observation levels were communicated effectively and the clinical decision-making involved in allowing him to leave after detention had been decided.

Richard Paul Martin Grant · Prevention of Future Deaths report View report

21 Apr 2016 Birmingham and Solihull E. Brown

Richard Paul Martin Grant was found deceased in his car in his garage on 7 January 2016 following inhalation of helium gas. He had previously self-harmed and threatened suicide, but his counselling referral was sent to the wrong team and an appointment was arranged for 22 February 2016. The report identified concerns about delays and failures in referring him to the appropriate mental health service and in informing his GP about the assessment and its outcome.

Aryan Akhgar · Prevention of Future Deaths report View report

3 Apr 2019 South Yorkshire (Western) S. Eccleston

Aryan Akhgar, aged 17, died on 6 March 2018 after hanging himself with the intent to take his own life. The report identified a gap in urgent mental health services for 16- and 17-year-olds in Sheffield: although an urgent response was recommended on 9 January 2018, the first visit by mental health professionals did not occur until 15 January 2018. The report also raised concern that funding for additional CAMHS resources was not guaranteed.

Richard Mark WHELAN · Prevention of Future Deaths report View report

9 Apr 2026 West Yorkshire (Western) P. Merchant

Richard Mark Whelan died on 15 December 2024 from exsanguination caused by incised wounds to both wrists after a deliberate act intended to end his life. In the preceding weeks, his mental health had deteriorated, and a referral to the Mental Health Trust Single Point of Access made on 11 December had not been acted on by the time of his death. The principal concern was that non-urgent referrals could take up to 14 days to be triaged, with a further plan only devised after triage.

Maureen Anne CAMPBELL-SCOTT · Prevention of Future Deaths report View report

27 Mar 2018 London (East) N. Persaud

Maureen Anne Campbell-Scott died from multiple injuries after falling from a ledge at the Exchange Shopping Centre car park on 16 June 2017. The report identified concerns about delays and errors in mental health referrals, delayed communication of medication changes, prescribing that did not always follow specialist directions, and a lack of joint working between mental health services and the GP practice.

Richard Jeffrey Jones · Prevention of Future Deaths report View report

20 Feb 2015 Wiltshire and Swindon I. Singleton

Richard Jeffrey Jones was at home alone and, during 14 to 15 October 2012, voluntarily ingested a quantity of tramadol that led to loss of consciousness, respiratory depression and aspiration of gastric contents, causing his death. The report raised concerns about recording and sharing information on risk and urgency, and about identifying primary responsibility when care was transferred between mental health services.

Michael John Valentine · Prevention of Future Deaths report View report

2 Feb 2016 Plymouth, Torbay and South Devon A. Cox

Michael John Valentine was found deceased on 16 September 2015 after a period in which he disclosed that he was not eating and stated that he had been on hunger strike. The concerns included an urgent mental health assessment referral being rejected without being brought to the relevant clinician’s attention, the failure to make a second referral after he reported not eating for 25 days, and the absence of discussion of these issues in the surgery’s significant events meeting.

Sapphire Kathleen BERNARD · Prevention of Future Deaths report View report

5 Feb 2025 West Sussex, Brighton and Hove P. Scofield

Sapphire Kathleen BERNARD was detained under the Mental Health Act and waited 19 days in an A&E department for a psychiatric bed while continuing to self-ligature. After admission to Langley Green Hospital, she self-tied a ligature while on intermittent observations and died at East Surrey Hospital on 30 October 2023. The principal concerns were the lack of psychiatric beds, the unsuitability of A&E as a holding environment for people needing mental health care, and vulnerabilities in the risk assessment and observation requirements at Langley Green Hospital.

Gemima CHRISTODOULOU-PEACE · Prevention of Future Deaths report View report

22 Jul 2024 Suffolk N. Parsley

Gemima Christodoulou-Peace was found suspended by her neck from a ligature and died from suspension hanging, with the inquest noting insufficient evidence that she intended her death at all material times. The report raises concerns about the absence of a single reference point for identifying medications associated with increased suicidal behaviour, limited recording and accessibility of mental-health telephone calls, and delays in access to prescribing mental-health support. Gemima had requested a medication review, but had not seen a prescribing mental-health practitioner before her death.

Elena WELLS · Prevention of Future Deaths report View report

23 Nov 2020 Brighton and Hove C. Palmer

Elena Wells, who had a history of mental health issues, died after placing a ligature around her neck while alone at home awaiting an urgent mental health admission. The report identified unclear responsibility and communication between the Local Authority and Mental Health Trust, and insufficient out-of-hours support and supervision while she waited for a bed.

Kingsley Burrell · Prevention of Future Deaths report View report

20 Mar 2015 Birmingham and Solihull L. Hunt

Kingsley Burrell died on 31 March 2011 after being restrained and transported between mental health and hospital settings following an acute mental health disturbance. The inquest found that the covering over his head, unreasonable periods of restraint, delay in resuscitation and neglect contributed to his death. Concerns included inconsistent national understanding of acute behavioural disturbance, the absence of a nationally implemented crisis-team system, and non-nationally consistent policies for managing patients between services during a crisis.

Nigel Byron Abbott · Prevention of Future Deaths report View report

22 Oct 2019 Birmingham and Solihull J. Bennett

On 27 July 2018, Nigel Byron Abbott was killed in a sustained assault by a man experiencing an acute psychotic episode who had been identified as posing a threat of violence but was not detained after mental health beds were reported to be unavailable. The report raised concerns about agencies misunderstanding the urgent use of section 135 powers and failing to work together effectively, potentially leaving acutely unwell people who pose risks to themselves or others unnecessarily free in public.

Maria Patricia Kelly · Prevention of Future Deaths report View report

27 Sep 2024 Inner North London M. Lee

Maria Patricia Kelly, who lived alone and was in poor health, was found deceased at home by police on 15 May 2024 after concerns were raised by neighbours and a housing officer. The report identifies prolonged lack of contact with primary care and mental health services, numerous failed encounters, and no welfare check until the neighbours’ concerns were raised; the inquest determined natural causes.

Dr Debatra Sircar · Prevention of Future Deaths report View report

7 Oct 2016 Inner South London A. Harris

Dr Debatra Sircar had longstanding alcohol dependency and depression, and died on 20 February 2016 after a fall associated with alcohol intoxication, causing subdural and intracerebral haemorrhage. He had been assessed as unsuitable for home treatment, but a Mental Health Act assessment was scheduled 11 days later, and he died before it took place. Concerns included the delay in securing hospital care and the absence of a clear interim care plan and responsibility for psychiatric monitoring.

Stephen Peter Church · Prevention of Future Deaths report View report

15 Jul 2014 Berkshire R. Sidhu

Stephen Church was found dead at the entrance to the multi-storey car park at Royal Berkshire Hospital on 13 May 2011 after absconding while detained under section 136 of the Mental Health Act 1983. The concerns included a broken chain of command resulting in only one police officer being responsible for his detention, insufficient understanding of an interagency working protocol, inadequate joint working to keep him safe, and delay in contacting an approved mental health professional to arrange a Mental Health Act assessment.

Nigel Harper · Prevention of Future Deaths report View report

2 Jun 2023 Worcestershire D. Reid

Nigel Harper, who had been experiencing severe depression and anxiety and thoughts of self-harm, took an intentional overdose of prescribed sedative and hypnotic medications on 8 July 2022 and died in hospital on 23 July 2022. The report identified a lack of understanding between two NHS Trusts about urgent mental health referrals, resulting in an urgent assessment not being arranged as intended and a continuing risk of similar deaths.