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Amy Marie Padley · Prevention of Future Deaths report View report

24 Feb 2025 Swansea and Neath Port Talbot K. Heaven

Amy Marie Padley suffered from alcohol addiction, depression and emotionally unstable personality disorder, and was found deceased at home on 8 July 2022 after taking her own life by suspension. The concerns included missed opportunities to refer her for community mental health assessment, insufficient guidance on managing co-occurring addiction and mental health conditions, and a reluctance to provide mental health support alongside addiction services.

Rebecca Louise Henry · Prevention of Future Deaths report View report

1 Aug 2019 Manchester West J. Pollard

Rebecca Louise Henry attempted to kill herself, was assessed in hospital and discharged as a voluntary patient who was considered not detainable. Later that day, she stood in front of an oncoming train; the principal concern was communication between mental health professionals and close relatives, particularly how confidentiality may limit the sharing of potentially valuable information.

Louise Turner · Prevention of Future Deaths report View report

7 Sep 2016 Exeter and Greater Devon L. Brown

Louise Turner died on 27 June 2014 from inhalation of helium after recently being discharged from a lengthy inpatient stay while receiving treatment for a serious mental health illness. The report raised concerns about inadequate post-discharge care and contact, ineffective duty and buddying arrangements, expectations that patients initiate contact, and the absence of female intensive psychiatric care beds in Devon.

Paige Jeannette ALLEN · Prevention of Future Deaths report View report

26 May 2023 South Wales Central G. Hughes

Paige Jeannette Allen died after falling from Southerndown Cliffs in the early hours of 21 April 2021, following an emergency services rescue attempt. The concern was that mental health practitioners assessing patients in crisis across different Cwm Taf Morgannwg University Health Board localities might not have immediate access to relevant medical records, potentially increasing the risk of incomplete or insufficient assessments.

Donna Marie Donnellan · Prevention of Future Deaths report View report

30 Nov 2023 Manchester North J. Kearsley

Donna Marie Donnellan had a long-standing history of disordered eating, severe weight loss and peripheral neuropathy. She was found deceased at home on 10 October 2022, and the investigation recorded death from complications arising from malnutrition likely due to an undiagnosed atypical eating disorder. Concerns included unclear roles between acute clinicians and the Mental Health Liaison Team, and a lack of understanding about referral pathways to specialist eating disorder services.

Leroy Patrick HAMILTON · Prevention of Future Deaths report View report

11 Jan 2023 Birmingham and Solihull L. Hunt

Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.

Stephen Taylor · Prevention of Future Deaths report View report

14 Jan 2026 Kent and Medway S. Clarke

Stephen Taylor experienced worsening mental distress linked to work and financial concerns, with escalating risk indicators and repeated contact with health services. He died on 26 May 2025 after deliberately jumping from Louisa Bay Cliffs. The principal concerns were the lack of coordinated escalation and ownership of risk across services, reliance on his denial of immediate intent despite other risk indicators, routine rather than urgent referrals, and the absence of a same-day urgent face-to-face assessment despite family concerns.

Sara Antonia MORAN, known as Sally · Prevention of Future Deaths report View report

28 Apr 2018 Blackpool and the Fylde A. Wilson

Sara Antonia MORAN, known as Sally, was found deceased at home on 22 April 2017 after being reported missing; the medical cause of death was morphine toxicity and the inquest conclusion was drug related. The report raised concern that excessive demands on mental health professionals and inadequate staffing could result in service users not receiving the attention they need, potentially with fatal consequences.

Imogen Alice NUNN · Prevention of Future Deaths report View report

24 Mar 2025 West Sussex, Brighton and Hove P. Schofield

Imogen Alice NUNN was found deceased at her home on 1 January 2023 after leaving a party and being reported as a high-risk missing person; the circumstances text states that she had consumed a substance bought online. The principal concern was the lack of available British Sign Language interpreters for Deaf patients receiving mental health support, particularly for urgent assessments when patients were in crisis.

Julius Jake Little · Prevention of Future Deaths report View report

28 Oct 2019 Inner North London G. Irvine

Julius Jake Little, a 20-year-old undergraduate living in university halls, was found unresponsive on 7 June 2019 with a ligature around his neck and was pronounced dead despite resuscitation efforts. The report raised concerns about how universities use disclosed mental-health information, including limited student responses to support offers and the lack of communication of disclosure information to tutors and halls staff.

John Richard William JONES · Prevention of Future Deaths report View report

19 Aug 2016 Inner North London M. Hassell

John Jones, aged 48, died instantaneously after jumping in front of a moving train at West Hampstead Railway Station on 18 April 2016. During his month-long admission to the Nightingale Hospital, he largely remained alone in his room and did not engage with the available group therapy. The principal concern was that the hospital environment appeared suboptimal for addressing his difficulty accepting help and providing effective treatment.

Allan Graham Joslin · Prevention of Future Deaths report View report

17 Jul 2019 Exeter and Greater Devon L. Brown

Allan Graham Joslin was found deceased partially on top of a tent near the North Devon Leisure Centre, Barnstaple, on 23 May 2018, after not being seen or contacted for several days. The report states that referrals for mental health assessment were not facilitated because of his known previous violent behaviour, and that he therefore received no formal assessment or treatment before his death. Concerns included inadequate facilities and policies for safely assessing patients with complex mental health, substance dependency and potential violence-related needs.

Mollie Rose Stansfield · Prevention of Future Deaths report View report

19 Dec 2022 East Riding and Hull P. Marks

Mollie Rose Stansfield, aged 22, died on 10 July 2019 after falling at Princes Quay, Hull, following her discharge from a place of safety under section 136 of the Mental Health Act 1983. The report identified failures at Hull Royal Infirmary to understand and correctly implement section 5(2) of the Mental Health Act 1983, with the relevant paperwork being invalid while Mollie was apparently subject to that section and subsequently absconded.

Laura McRory · Prevention of Future Deaths report View report

13 Jun 2016 London (East) N. Persaud

Laura McRory, who had a history of anxiety, depression and alcohol misuse, was assessed at hospital on 20 June 2015 after deterioration in her mental state and increased alcohol consumption. She was discharged without immediate follow-up or continued observation and was found unresponsive the following day; she died from alcohol and mixed drug consumption. The principal concerns were the adequacy of the discharge safety plan and the lack of a clear process for referring NELFT staff seeking mental healthcare to another Trust when they were unwilling to share information with colleagues.

Helen Jane Kerr · Prevention of Future Deaths report View report

18 Sep 2024 Surrey C. Topping

Helen Jane Kerr had a history of drug and alcohol abuse, developed psychosis, and died by hanging after being found dead at a refuge on 3 April 2023. The report identified concerns about failures to respond appropriately and promptly to information about her deteriorating mental health, inadequate assessment and treatment, limited out-of-hours information sharing, and failure to inform the refuge about risks associated with her presentation.

Daniel Cameron SHORROCKS · Prevention of Future Deaths report View report

1 Aug 2019 Plymouth, Torbay and South Devon I. Arrow

Daniel Cameron SHORROCKS discussed ending his life with a friend on 1 January 2018, sent a text stating “Dead at Berry Head”, and was found dead at the foot of a cliff at Berry Head. The report’s concerns relate to the availability of qualified and experienced staff for local authorities with many young people in care, and the integration of care, adolescent mental health, and education pastoral services.

Lauren Elizabeth Bridges · Prevention of Future Deaths report View report

19 Sep 2023 Manchester South A. Bridgman

Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.

Jason Pendlebury · Prevention of Future Deaths report View report

12 Mar 2020 Manchester North M. Cox

Jason Pendlebury, a known cocaine user, fell from the roof of a block of flats on 29 September 2018 and died in hospital on 2 October 2018 after sustaining serious injuries. The principal concerns related to communication and information-sharing between Greater Manchester Police, North West Ambulance Service, the GP and mental health professionals about his potential mental health needs and risk.

Alice LITMAN · Prevention of Future Deaths report View report

5 Dec 2023 West Sussex, Brighton and Hove S. Clarke

Alice Litman, a 20-year-old trans female, was found dead on 26 May 2022 after a descent from height. The report raised concerns about mental-health training and support for transgender people, delays in accessing gender-affirming healthcare, and insufficient clarity and provision of care while awaiting treatment.

Andrew Reid · Prevention of Future Deaths report View report

10 Apr 2018 Manchester South A. Mutch

Andrew Reid was found suspended from a ligature at Longford Park on 17 October 2017. The inquest concluded that his death was suicide and recorded the medical cause of death as hanging. Concerns related to differences in mental-health service provision and referral routes for residents of Manchester and Trafford, including the lack of out-of-hours emergency GP referrals in Trafford and the requirement for patients to attend A&E.