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Thomas Edward Curtin · Prevention of Future Deaths report View report

14 Mar 2018 Cornwall and Isles of Scilly E. Carlyon

Thomas Edward Curtin, who was detained under the Mental Health Act on an acute mental health ward, absconded during escorted leave and later died in hospital on 20 August 2016 from heroin intoxication. The report raised concern that private locked rehabilitation providers were not subject to a national response-time framework, potentially leaving patients on wards inappropriate for their needs while awaiting placement.

NICHOLAS JAMES GLAVIND DYMOND · Prevention of Future Deaths report View report

21 Dec 2023 Exeter and Greater Devon A. Longhorn

Nicholas Dymond, who had a history of intermittent drug use, developed paranoia and expressed suicidal thoughts about jumping in front of a train. After a Mental Health Act Assessment following his arrest, he was discharged and ran away when the arranged taxi arrived; less than three hours later, he stepped in front of a train and was pronounced deceased at the scene. The concerns identified included independent doctors potentially conducting assessments without access to patient records and witnesses’ lack of understanding of voluntary admission and the least restrictive option.

Gaia Kima Pope-Sutherland · Prevention of Future Deaths report View report

21 Jul 2022 Dorset R. Griffin

Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.

Oliver Sharp · Prevention of Future Deaths report View report

1 Oct 2019 Manchester South A. Mutch

Oliver Sharp died after taking a fatal dose of heroin; his death was confirmed at Wythenshawe Hospital on 18 October 2018. The inquest identified concerns about failures by mental health services to recognise and respond to his increasing level of risk during his transition from child and adolescent mental health services to reduced post-16 provision, as well as concerns about delays in autism assessment and variation in post-16 services.

Caroline Antoinette Scott · Prevention of Future Deaths report View report

21 May 2018 Milton Keynes T. Osborne

Caroline Antoinette Scott, who had depression and thoughts of suicide, was found hanging at home on 30 May 2017 and died in hospital on 2 June 2017. The inquest identified a failure to carry out a mental health assessment after recognising that she was in crisis, resulting in a lost opportunity to refer her for treatment. Concerns were also raised about the adequacy of out-of-hours emergency mental health services and whether emergency referral policy was understood by all medical services in Milton Keynes.

Mr Matthew Jones · Prevention of Future Deaths report View report

3 Jun 2019 Bedfordshire and Luton E. Whitting

Mr Matthew Jones, who had paranoid schizophrenia and polysubstance misuse, was discharged from hospital to minimally supported temporary accommodation and suffered a cardiac arrest shortly afterwards; his death was attributed to cocaine toxicity. The report identified concerns about inadequate training and poor coordinated, multi-agency working, including insufficient attention to housing in hospital discharge planning.

Leslie Johnson · Prevention of Future Deaths report View report

28 Jul 2016 Manchester City N. Meadows

Leslie Johnson, who required supported care and had a swallowing assessment recommending a soft diet and supervision, died in hospital after being left unsupervised while eating an egg mayonnaise sandwich. A post-mortem examination found that he died from acute aspiration of food. Concerns included failures to assess or recognise his lack of mental capacity and failures to communicate his care plan and swallowing requirements between community carers and the hospital.

Hannah Elizabeth Browning · Prevention of Future Deaths report View report

13 Apr 2021 North Wales (East and Central) J. Gittins

Hannah Elizabeth Browning, who was receiving treatment for mental health issues and had a history of self-harm and suicidal thoughts, expressed an intention to end her life on 10 October 2018. She subsequently placed a ligature around her neck and sustained a hypoxic brain injury, dying at Wrexham Maelor Hospital on 12 October 2018. The principal concern was that inadequate arrangements and insufficient efforts were made by Mental Health Services to protect her and contact her after she indicated an immediate risk of harm.

Billy James Jenkins · Prevention of Future Deaths report View report

21 Feb 2020 South London J. Devonish

Billy James Jenkins was found hanging by the neck in a hotel room bathroom on 12 August 2019, following a history of low mood, alcohol and cocaine abuse, suicidal ideation and previous suicide attempts. The concerns included limited information gathering during his mental health assessment, a decision that he did not have a mental health condition without further assessment, inadequate documentation and planning, and possible over-reliance on alcohol and drug use as the explanation for his suicidal ideation. The inquest concluded that he took his own life following an assessment after which he felt helpless because there had been no clear mental state examination and a potential missed opportunity to consider an appropriate referral.

Mr Parminder Singh Sanghera · Prevention of Future Deaths report View report

12 Aug 2024 Black Country Z. Siddique

Mr Parminder Singh Sanghera was arrested after displaying erratic behaviour, including running naked, and was taken to hospital before being held in police custody. He was released without charge on 13 February 2023 and was later found deceased in a canal near the custody suite. The principal concern was that, despite his behaviour and vulnerability, no full mental health assessment was undertaken before his release and risk assessments did not identify a risk of suicide or self-harm.

Terence Robert TUTTLE · Prevention of Future Deaths report View report

9 Aug 2021 Norfolk Y. Blake

Terence Robert Tuttle, who lived in a care home, was admitted to hospital after testing positive for Covid-19 and was treated for acute kidney injury, pneumonia and a bleeding duodenal ulcer. His recorded poor oral intake was not acted on promptly, and he lost significant weight before being transferred to another nursing home, where he died three days later. The concerns included delayed dietetic and mental health assessments, inadequate action on weight loss, difficulties applying the Mental Capacity Act, insufficient care for a mentally unwell patient refusing food, exclusion of family from involvement in his care, and lack of recognition of serious harm.

Sally Poynton · Prevention of Future Deaths report View report

14 May 2024 Cornwall and Isles of Scilly A. Cox

Sally Poynton, aged 44, was fatally stabbed by her son on 22 June 2021. The report raised concerns about failures in mental-health assessment and follow-up, including inadequate discharge information, difficulties obtaining reassessment, referral handling, communication with family, and discharge without clinical consideration despite signs of deteriorating mental health.

Simon Moss · Prevention of Future Deaths report View report

1 Feb 2026 Inner South London X. Mooyaart

Simon Moss was discovered on the roof of his family home on 14 February 2024 after recently developing paranoid thinking, becoming extremely anxious and appearing to be considering suicide. After ambulance attendance and a mental health assessment that did not use detailed information in the ambulance record or contact his wife for collateral information, he was discharged and deliberately fell from a nearby building to his death later that day. The concern was that gaps in training, practice, policy or procedures could result in important risk information and family contact details not being used, undermining the assessment and mitigation of risk to patients presenting with potential risk to self.

Daniel Hubert Collins · Prevention of Future Deaths report View report

14 Sep 2018 Birmingham and Solihull J. Bennett

Daniel Hubert Collins attempted to take his own life by overdose on 07/04/18 and was discharged from hospital and then from the FTB crisis team, with responsibility placed on him to contact counselling services. He went missing on 26/04/18 and was found deceased in woodland on 28/04/18; the medical cause of death was venlafaxine overdose. The report identified concern that the transfer between mental health services was not communicated or followed up, creating a risk that patients in or recently out of crisis could be lost to mental health services.

Natasha Elizabeth Victoria Abrahart · Prevention of Future Deaths report View report

16 May 2019 Avon M. Voisin

Natasha Elizabeth Victoria Abrahart died on 30 April 2018 after placing a ligature around her neck. She was under the care of a mental health team that had not provided a timely and detailed management plan following several assessments. The report also identifies concerns that follow-up after starting sertraline, including review of suicide risk, did not comply with the cited NICE guideline; the inquest concluded that the death was suicide contributed to by neglect.

Michael William Cooper · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Michael William Cooper was found dead at home on 22 June 2018 from constriction by a ligature around the neck. The report describes concerns about the lack of face-to-face follow-up and immediate action despite indications of high suicide risk, as well as shortages of inpatient beds, team capacity and funding in mental health services.

Benjamin Rajinder O’HARA · Prevention of Future Deaths report View report

17 Mar 2021 Inner North London M. Hassell

Benjamin Rajinder O’Hara died after jumping from the fourth floor balcony of his home on 2 November 2020, following repeated contacts with mental health services and episodes of suicidal thoughts and psychosis. Concerns included that professionals did not ask permission to contact his family, an outdated hospital-admission alert was not reviewed, a review was not a formal mental health assessment, and he had no care co-ordinator or other community mental health team member overseeing his care.

Daisy French · Prevention of Future Deaths report View report

9 Nov 2017 South Yorkshire (Western) L. Slater

Daisy French, who had a history of serious mental health difficulties and was transitioning from child to adult mental health services, died after deliberately placing herself in front of a high-speed train at Meadowhall Railway Station on 19 April 2017. The concerns included communication and information sharing between services, transition of care, differing out-of-hours arrangements for 16- to 18-year-olds, placement of an under-18-year-old in an adult crisis house, and returning her to accommodation without staff on duty after a mental health assessment.

Hayley Jayne Cowan · Prevention of Future Deaths report View report

29 May 2024 Manchester North J. Kearsley

Hayley Jayne Cowan was detained under Section 3 of the Mental Health Act and absconded during accompanied leave to a local shop on 3 June 2022. She was found deceased the following day after using drugs; concerns included inconsistent definitions and guidance for accompanied and escorted leave, including what staff should do if they needed to use the bathroom while accompanying a patient.

Christopher Swain · Prevention of Future Deaths report View report

14 Dec 2020 West Sussex P. Schofield

Christopher Swain, who was detained under Section 3 of the Mental Health Act 1983, was found unresponsive in his room at Langley Green Hospital on 22 September 2019 with a ligature around his neck and was confirmed deceased by paramedics. Concerns included inconsistent staff practices when conducting observations, uncertainty about when he was last seen alive, the absence of a formal mental health review, care plan and adequate risk assessment, inadequate record-keeping, no recorded therapeutic engagement, and failure to provide staff to accompany a sectioned patient to another hospital.