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Diana Ocean Grant · Prevention of Future Deaths report View report

24 Nov 2025 Surrey R. Travers

Diana Ocean Grant, who was experiencing a relapse of paranoid schizophrenia and symptoms of psychosis, died in her prison cell after a foreign object became lodged in her upper airway. The report identified concerns about failures and delays in mental health assessment, treatment, information-sharing, observation and prison placement, as well as the limited availability of secure mental health beds for people requiring admission.

Dudley Vincent Brown · Prevention of Future Deaths report View report

27 Jun 2018 Inner North London S. Bourke

Dudley Vincent Brown had multiple health conditions and his care package was withdrawn after incidents involving threats to carers and a social worker. He was found at home in a state of reduced consciousness during a delayed mental health assessment, taken to hospital with multi-organ failure, and died on 11 January 2018. Concerns included the withdrawal of care without welfare checks, misunderstandings about referral responsibilities, and delays involving the mental health assessment and police risk assessment.

Mr Gunaratnam Kannan · Prevention of Future Deaths report View report

30 Oct 2025 Nottinghamshire S. Wood

Mr Gunaratnam Kannan took an overdose of Metformin and Indapamide tablets on 18 March 2025 and initially refused hospital treatment after being assessed as having mental capacity. He was later found confused, with limited consciousness and lacking mental capacity, was taken to hospital, suffered a cardiac arrest and was pronounced deceased on 19 March 2025. The concerns identified were a lack of joint-agency policy and training on Mental Capacity Act and Mental Health Act assessments, including uncertainty about which service should request or undertake a Mental Health Act assessment.

Charlotte Tetley · Prevention of Future Deaths report View report

14 Sep 2025 Cheshire S. Murphy

Charlotte Tetley died after deliberately sitting on railway tracks and being struck by a train on 24 September 2024. The report describes concerns that she was removed from the inpatient bed list before an appropriate mental health review had taken place, despite previous documented reviews stating that inpatient admission was required.

Sarah Frances BOYLE · Prevention of Future Deaths report View report

2 May 2025 Cheshire V. Davies

Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.

Ryan Louis Ouslem · Prevention of Future Deaths report View report

24 Sep 2024 West Sussex, Brighton and Hove R. Simpson

Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.

Abigail Eleanor Ann Jelly · Prevention of Future Deaths report View report

13 Oct 2025 Hampshire, Portsmouth and Southampton N. Walker

Abigail Eleanor Ann Jelly, a 34-year-old mother of two experiencing post-natal depression, died on 12 November 2024 after intentionally harming herself, causing fatal blood loss. The report identified concerns about inadequate perinatal mental-health training, limits on urgent specialist visits, insufficient engagement with her parents, and wider failings in professional curiosity, escalation, decision-making and risk assessment.

Graeme Alexander Kidd · Prevention of Future Deaths report View report

23 Jul 2014 Norfolk J. Lake

Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.

Danyon Robert Chesters · Prevention of Future Deaths report View report

26 Feb 2019 Manchester South A. Mutch

On 2 July 2018, Danyon Robert Chesters went onto a railway line under Trafford Bridge Road and was struck by a train. The inquest heard concerns about delays in accessing mental health services, the resulting use of private therapy, and a lack of joined-up care and information sharing. It also heard concerns that private therapists might not obtain information about prescribed mental health medication and its impact on therapy.

Richard Patrick Carlon · Prevention of Future Deaths report View report

22 Jul 2019 Birmingham and Solihull L. Hunt

Richard Patrick Carlon, who had paranoid schizophrenia and a history of relapsing after taking illicit substances, was detained under the Mental Health Act after stating that he would kill himself. He later left care, was found at his father’s home, and subsequently stepped in front of a lorry; he died in hospital from polytrauma following the road traffic collision. The concerns included the lack of an approved Mental Health practitioner to conduct an assessment and failures in communication between the police and mental health services after he was found safe and well.

Suzanne Julia ELLERBY · Prevention of Future Deaths report View report

14 Nov 2025 Surrey A. Loxton

Suzanne Ellerby was found deceased at her father’s home in Addlestone, Surrey, on 4 January 2025, after a period of mental health deterioration and no contact with mental health or medical practitioners since 13 December 2024. The principal concern was the transfer of vulnerable patients from secondary mental health services to primary care without universal guidance, safety-netting, or arrangements to ensure timely follow-up, leaving patients responsible for arranging care themselves.

Uyapo Theodore Hayunga-Macha · Prevention of Future Deaths report View report

20 Sep 2021 Liverpool and the Wirral A. Rebello

Uyapo Theodore Hayunga-Macha went missing from Arrowe Park Hospital on 4 December 2020 before he could be assessed for his mental health. He was found drowned on 9 March 2021, and it remained unclear how he ended up in the water. Concerns were raised about why he was not looked after and why he was left alone while waiting for assessment.

Matthew Marc GROOM · Prevention of Future Deaths report View report

12 Nov 2015 Inner North London M. Hassell

Matthew Marc Groom stood in front of a lorry after spending seven hours in the emergency unit of Whittington Hospital, where he was seen by emergency medicine and mental health staff. Concerns included delays in his mental health assessment, prescribed diazepam not being administered, inadequate planning for his possible departure, failure to seek urgent hospital security assistance, and incomplete communication with police.

Nicholas Kim Harrison · Prevention of Future Deaths report View report

24 Apr 2024 Swansea and Neath Port Talbot K. Heaven

Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.

Leighton Alan Dickens · Prevention of Future Deaths report View report

29 Sep 2023 South Wales Central D. Regan

Leighton Alan Dickens died by incomplete atypical hanging alone at his home address on 14 October 2020. The inquest heard that police did not detain him at hospital for mental health assessment, and identified limited access to qualified, clinically informed mental health advice and records for officers responding to community mental health crises.

Joanna Leven · Prevention of Future Deaths report View report

30 Apr 2021 Manchester South C. Morris

Joanna Leven was found dead at home on 26 March 2020 after self-induced asphyxia, following a deterioration in her mental health after her dog became seriously unwell and was euthanised. The report identified concerns about the absence of a comprehensive mental health assessment, variable access to therapeutic pathways and trauma-focused services, and the risk of information being lost between hospital and mental health liaison records systems.

David Stables · Prevention of Future Deaths report View report

6 Dec 2024 South Yorkshire (Western) M. Whittle

David Stables had a history of mental health issues and attended his GP in February and March 2024 with anxiety, sleep difficulties and poor appetite. The inquest concluded that he died by suicide, with bilateral transection of the ulnar arteries and incised wounds to the wrists. The principal concern was that no mental health or medication reviews were recorded between April 2020 and February 2024, and it was unclear whether reviews had taken place but were not recorded or had not taken place when they should have.

Nicola RAYNER · Prevention of Future Deaths report View report

7 Mar 2024 Suffolk N. Parsley

Nicola Raynor was found hanging on 6 June 2023 and later died at Addenbrookes Hospital from a hypoxic brain injury. The report raises concerns about the lack of available informal mental health inpatient beds locally and nationally, including continuing insufficient bed capacity for patients awaiting admission.

Peter Franklin · Prevention of Future Deaths report View report

19 May 2014 Mid Kent and Medway P. Harding

Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.

Patricia Ann Cleghorn · Prevention of Future Deaths report View report

25 Jul 2016 Birmingham and Solihull L. Hunt

Patricia Ann Cleghorn, who had suicidal ideation and was awaiting an inpatient mental health bed, was found collapsed at home after receiving diazepam and was declared dead by paramedics on 14 December 2015. The concerns were the lack of an available inpatient bed, allowing her to self-medicate with potentially dangerous drugs despite repeated statements that she intended to overdose, and the absence of a formal risk assessment.