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Matthew John LYNCH · Prevention of Future Deaths report View report

4 Mar 2025 Birmingham and Solihull L. Hunt

Matthew John Lynch was attacked in the garden of his supported living accommodation in Birmingham on 11 July 2023 and was killed by decapitation. The concerns included whether medication non-compliance and a change of address had been adequately followed up, the quality of mental health assessments, and information sharing and training between mental health services, the council, housing providers and support workers.

Mark Wolfe Kinzley · Prevention of Future Deaths report View report

26 Mar 2024 East London G. Irvine

Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

Maria STANCLIFFE-COOK · Prevention of Future Deaths report View report

8 Jul 2021 Avon M. Voisin

Maria STANCLIFFE-COOK was found dead on 1 August 2019 after intentionally taking her own life using helium, causing asphyxiation. The principal concern was that her suicide risk was downgraded from high to medium by members of the mental health team who had not previously dealt with her, followed by a brief telephone contact that did not include an assessment or plan to manage her risk.

DECLAN GORDON GERARD MORRISON · Prevention of Future Deaths report View report

23 Oct 2024 Cambridgeshire and Peterborough S. Milburn

Declan Morrison, who had complex care needs and required 24-hour residential care, was detained under the Mental Health Act after no suitable alternative placement could be found. He was found unresponsive after suffering catastrophic brain injuries and died in hospital on 2 April 2022. The principal concerns were the shortage of suitable community and NHS placements and the use of a Section 136 Suite considered inappropriate for his longer-term detention and complex needs.

Daniel Jeffrey Moran · Prevention of Future Deaths report View report

15 Jan 2020 Manchester West R. Syed

Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.

Miss Kirsty Walker · Prevention of Future Deaths report View report

19 Dec 2018 Surrey A. Crawford

Miss Kirsty Walker died in hospital on 27 September 2015 after being found unresponsive in prison with a ligature tied around her neck. She had a history of self-harm and had engaged in 235 acts of self-harm during her imprisonment, including 215 involving ligatures. The report raised concern that prisoners were taking well over 14 days to transfer to secure hospitals under section 47 of the Mental Health Act 1983, presenting a risk of further deaths.

Adrian Jennings · Prevention of Future Deaths report View report

19 Apr 2018 Manchester South A. Mutch

Adrian Jennings had a history of mental health issues and self-harm attempts and died on 10 December 2016 after taking a fatal cocktail of drugs and alcohol. The principal concerns included poor communication and inadequate discharge support planning between mental health services, failures to record key information when he arrived at hospital, and a policy gap concerning the reporting of high-risk absconding before triage.

Lewis Charles Francis · Prevention of Future Deaths report View report

23 Mar 2020 Exeter and Greater Devon N. Rheinberg

Lewis Charles Francis was arrested after stabbing his mother while acutely psychotic and was remanded to HM Prison Exeter after no ready medium secure mental health hospital transfer facility was available. He died at the prison on 24 April 2017 by suicide as a result of suspension by a ligature. Concerns included the lack of a ready transfer mechanism from police custody to medium secure mental health facilities, and insufficient understanding of the needs and vulnerabilities of prisoners on the autistic spectrum.

Naomi Aylott · Prevention of Future Deaths report View report

29 Sep 2025 Hampshire, Portsmouth and Southampton R. Simpson

Naomi Aylott died on 12 September 2024 after jumping from a railway bridge with the intent to end her own life, following a period of poor mental health and previous suicide attempts. Concerns included that she was not seen face to face by her care co-ordinator, formal risk assessments and care planning were not completed, risk-assessment training and auditing were inadequate, and family involvement during telephone-based care had not been properly considered.

Shelemiah Pedajah PETERKIN · Prevention of Future Deaths report View report

20 Jun 2024 Birmingham and Solihull A. Hodson

Shelemiah Pedajah PETERKIN was reported missing on 2 October 2023 and was found deceased at home after police forced entry. The inquest concluded suicide following intentional poisoning. Concerns included staffing shortages and delays in mental-health referrals, as well as incomplete early-warning-sign documentation and delayed action to address clinical standards, creating risks of missed assessment, intervention and treatment opportunities.

Adrian Michael James · Prevention of Future Deaths report View report

7 Mar 2024 Inner West London F. Wilcox

Adrian Michael James died after falling from the fourth-floor balcony of his block of flats while experiencing severe and enduring mental illness, including paranoia and a high background risk of suicide. The principal concerns were that he was not assessed by a consultant, proactive care was not considered during his mental health crisis, insufficient attention was given to impulsive suicide risk, no follow-up assessment occurred after a police-interrupted treatment session, and communications between services were inadequate.

Alice Amaryllis Gibson-Watt (“Alice”) · Prevention of Future Deaths report View report

18 May 2017 London (West) S. Ormond-Walshe

Alice Gibson-Watt developed postpartum psychosis and, after receiving Haloperidol during seclusion in an acute mental health ward, suffered cardiac arrest and later died from hypoxic brain damage on 20 November 2012. The report raised concerns about inadequate monitoring and documentation of vital signs, missed opportunities for medical assessment and ECG, delayed recognition of the arrest, and delays in commencing CPR and using a defibrillator.

Marshall Metcalfe and Jane Ireland · Prevention of Future Deaths report View report

25 Nov 2021 Blackpool and the Fylde A. Wilson

Marshall Metcalfe was transferred to hospital after sustaining catastrophic injuries on 7 May 2020, where his death was verified. Jane Ireland was found deceased at home on 7 June 2020, after the death of her seventeen-year-old son; the report records toxic effects, fatty liver disease and bronchopneumonia in relation to her death, while her intent could not be established. The principal concern was the lack of Children’s Social Care involvement in Marshall’s discharge planning and the potential future risk arising when social care cases are closed during mental health admissions and require re-referral before discharge.

Samantha Kate YOUNG · Prevention of Future Deaths report View report

25 Jul 2025 Hampshire, Portsmouth and Southampton H. Charles

Samantha Young died at home on 20 November 2023 after intentionally taking her own life by hanging. She had a history of mental health difficulties, previous suicide attempts, and worsening condition amid significant stress. The concerns included insufficient training for agency staff in risk assessments and inadequate contact and communication with patients’ families and friends.

James Warren Agius · Prevention of Future Deaths report View report

7 Oct 2024 Essex S. Hayes

James Warren Agius was found deceased at home on 17 December 2022 after suspending himself, with the inquest concluding suicide by suspension by ligature. The concerns included significant omissions in his medical records, an incomplete risk assessment following a suicide attempt, differing views about whether he displayed hypomanic symptoms, and no evidence that new national risk-assessment training had been implemented by the Trust.

Elizabeth Godwin · Prevention of Future Deaths report View report

19 Jun 2015 Wiltshire and Swindon I. Singleton

Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.

Paul Alexander Meadows · Prevention of Future Deaths report View report

29 Jun 2022 Suffolk P. Taheri

Paul Alexander Meadows was found dead at home on 4 August 2021 after taking a Codeine overdose, against a background of physical health difficulties and deteriorating mental health. The report identified concerns that his mental health crisis was not recognised by the First Response Service on 3 August 2021 and that there was no onward referral for urgent or emergency intervention. It also identified broader concerns about the time available to practitioners to gather information and properly triage and risk assess callers, linked to workload and recruitment pressures.

Alex Dews · Prevention of Future Deaths report View report

10 Oct 2023 South Yorkshire (Western) A. Combes

Alex Dews went to a bridge at Dearne Valley Country Park on 14 July 2022, fell into shallow water, and died at Sheffield Children’s Hospital on 18 July 2022. The report raises concerns about school documentation and assessment processes, barriers to referral to NHS mental health services, unclear allocation of school-procured psychology support, and inadequate communication with the support provider.

Judith Maike OBHOLZER · Prevention of Future Deaths report View report

12 Jul 2024 Inner West London E. Oakley

Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.

Kevin Anthony Ince · Prevention of Future Deaths report View report

18 Nov 2024 Lancashire and Blackburn with Darwen C. Long

Kevin Anthony Ince was detained under the Mental Health Act 1983 and became unwell at Kem Ple View Hospital on 24 October 2023. He was taken to hospital, where his condition deteriorated, and he died on 25 October 2023 from right ventricular failure caused by acute interstitial pneumonitis associated with vaping-related lung injury. The concerns included insufficient consideration of responses when detained patients refused necessary medical treatment and insufficient action when a detained patient routinely declined food over a prolonged period.