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Anthony Robert CARD · Prevention of Future Deaths report View report

7 Nov 2025 Suffolk P. Taheri

Anthony Robert CARD, known as Tony, died by suicide by suspension by ligature at 15 Duke Street, Ipswich, between about noon on 21 and 22 November 2023. The report identifies a concern that, outside Care Act safeguarding criteria, there was no mechanism for police to communicate medium-risk mental-health information to relevant medical or mental-health providers, potentially resulting in missed support or affecting later decision-making.

Mr Robin Andrew Ward · Prevention of Future Deaths report View report

18 Oct 2024 Northamptonshire H. Shah

Mr Robin Andrew Ward, a 73-year-old man, died by drowning in a bath at the Warren Crisis House on 4 July 2021; the conclusion was that his death was suicide. He had required an acute inpatient mental health bed, but no local bed was available for four days and he was placed at the crisis house as an interim measure. Concerns included pressures on acute and out-of-area mental health bed availability, the lower clinical capacity and lack of ligature safety in crisis houses, and long waiting times for psychological assessment.

Gary McDonald · Prevention of Future Deaths report View report

20 Sep 2022 Worcestershire D. Reid

Gary McDonald was found deceased in his cell at HMP Hewell after spending nearly four months on remand awaiting trial; the inquest concluded that he died as a result of suicide. The principal concern was that, despite prison healthcare receiving records showing a history of depression and two previous overdoses, including one seven months earlier, there was no system to follow up discrepancies between a prisoner's disclosed mental health history and community GP records.

Gareth WILLIAMS · Prevention of Future Deaths report View report

31 Aug 2022 Gwent C. Saunders

Gareth Williams, who had worsening tinnitus and declining mental health with suicidal thoughts, was discovered hanging on 23 August 2021 and could not be revived. The concern was that he was left without sufficient support because mental health and ENT services transferred him between teams without directly communicating.

Sandra Brotherton · Prevention of Future Deaths report View report

8 Dec 2016 Manchester South J. Kearsley

Sandra Brotherton was killed at her home on 31 December 2014, shortly after returning from hospital. The inquest heard that she had been the predominant and effectively sole carer for a person with a dual diagnosis of paranoid schizophrenia and Asperger’s Syndrome, who had been alone at home during her hospital stay. Concerns included the lack of a clearly discussed contingency plan, inadequate documentation and sharing of care-plan information with the Personal Assistant, difficulty obtaining an urgent psychiatric appointment, and insufficient follow-up after Sandra requested that he be rehoused immediately.

Louise Dawn Locke · Prevention of Future Deaths report View report

29 Jan 2016 Central Hampshire G. Short

Louise Dawn Locke, a vulnerable adult with undiagnosed mental problems associated with alcohol dependency, died by suicide after hanging herself at her home in Winchester on 27 May 2015. The concerns included her premature discharge from mental health services without a proper risk assessment or adequate support, and inadequate systems for collating information across agencies to identify and support people at high risk.

Natalia Violet Cestaro (known as “Tali”) · Prevention of Future Deaths report View report

14 May 2026 Coventry and Warwickshire L. Lee

Natalia Violet Cestaro, known as “Tali”, was an 18-year-old inpatient who died on 15 November 2023 after ingesting a foreign object, undergoing endoscopic removal, and subsequently developing gastric perforation, sepsis and multi-organ failure. The principal concerns included the proactive assessment of risks from impulsive ingestion, liaison between mental health and acute services, and assurance and auditing of communication processes.

Leva Amra ADRIS · Prevention of Future Deaths report View report

8 Nov 2023 Birmingham and Solihull E. Brown

Leva Amra Adris was pronounced deceased on 18 March 2023 after suffering a fitting episode, and post-mortem testing identified toxicity following an overdose of medication used for anxiety. The report raised concerns that a GP referral requesting secondary mental health assessment was not considered by secondary services, that the GP was not informed it had been rejected, and that the significance of worsening mental health symptoms may have been underestimated.

Paul Robert Allan · Prevention of Future Deaths report View report

25 Jul 2018 Inner West London R. Caller

On 16 July 2017, Paul Robert Allan walked onto the track at Oxford Circus tube station and was struck by a westbound train. Concerns included his discharge from the Rochdale Community Mental Health Team without transfer to the corresponding team in Stoke, and a failure to consult or work with drug and alcohol advisory services.

Jessica Lynda Smithson · Prevention of Future Deaths report View report

8 Aug 2025 Manchester North J. Kearsley

Jessica Lynda Smithson, aged 27, died by suicide after contacting a crisis text mental health service following an alleged serious sexual assault. The service did not contact the Metropolitan Police despite messages indicating an immediate risk to her life. The report identified concerns about inconsistent procedures among charity crisis text services and the absence of a commissioned crisis text mental health service in Greater Manchester.

Mr Oleg Khala · Prevention of Future Deaths report View report

6 Jul 2023 Inner West London F. Wilcox

Mr Oleg Khala, who had complex mental and neurodevelopmental illnesses and was vulnerable, died by hanging after being discharged twice from hospital despite requesting admission because of suicidality and sleeplessness. The principal concerns included generic CATT assessments, discharge without consultant discussion, failure to provide a care coordinator, and insufficient access to neurodevelopmental expertise.

Philip John BATTLE · Prevention of Future Deaths report View report

25 Nov 2022 Liverpool and the Wirral A. Rebello

Philip John Battle died by suicide on 8 July 2022 after contacting the ambulance service about an overdose and an attempted hanging. The report raised concerns that the ambulance triage process focused on physical health rather than immediate mental-health and self-harm risks, and that no attempt was made to contact someone who could check on his safety. It also identified limited coordination and shared mental-health crisis resources between ambulance, police and health services.

Chloe Louise Barber · Prevention of Future Deaths report View report

12 Aug 2025 East Riding and Hull P. Marks

Chloe Louise Barber, who had a history of self-harm and multiple overdoses and had been detained under the Mental Health Act, was found at home on 3 November 2021 and was confirmed dead at 17:05. The report identified concerns about transition pathways between CAMHS and adult psychiatric services, guidance on administering depot antipsychotic preparations, and understanding of section 117 aftercare responsibilities.

Ellame FORD-DUNN · Prevention of Future Deaths report View report

3 Feb 2026 West Sussex, Brighton and Hove J. Andrews

Ellame FORD-DUNN, aged 16, was detained on an acute paediatric ward because no Tier 4 Paediatric Mental Health bed was available. She absconded from the ward during a toilet visit and died following her absconding. The principal concerns included insufficient Tier 4 beds, inadequate security and risk management, inconsistent handovers and unclear procedures for responding to absconsion, and poor coordination between agencies.

Sarah Margaret Clarke · Prevention of Future Deaths report View report

16 May 2021 Surrey K. Henderson

Sarah Margaret Clarke, a 23-year-old university student with significant mental health difficulties, was found deceased in her university accommodation on 21 November 2019 after sending an email indicating that she intended to end her life. The concerns included inadequate follow-up after she became extremely distressed, insufficiently robust systems for managing and safeguarding students at high risk of self-harm, and failure to implement relevant national guidance or provide adequate oversight and learning.

Ms Safoora Alam · Prevention of Future Deaths report View report

6 Dec 2019 Black Country Z. Siddique

Ms Safoora Alam had complex physical health problems, ongoing pain and mobility issues, and a history of impulsive overdoses and suicidal thoughts. On 28 January 2019, she set fire to her bed and herself, sustained burns to at least 80% of her body, and died later that day. The principal concerns were inconsistent sharing of documentation between agencies, inadequate joint working and information gathering, and a slow and ineffective urgent referral process when risks to her mental health escalated.

Liam Paul McCarlie · Prevention of Future Deaths report View report

24 Jun 2024 Northamptonshire J. Dixey

Liam Paul McCarlie died by suicide after being found suspended by a ligature on 1 April 2023; death was confirmed shortly after midnight on 2 April 2023. The inquest identified a significant delay in ambulance attendance, which contributed to his death, and an insufficiently clear mental-health support plan while he awaited assessment for the Structured Clinical Management programme. A further concern was that mental-health professionals in the ambulance service’s emergency operations centre did not have access to relevant community mental-health records.

Vanessa Christine DADSWELL · Prevention of Future Deaths report View report

17 Feb 2016 Surrey S. Wickens

Vanessa Dadswell died from injuries after placing herself in the path of an oncoming train at Whitley Railway Station on 2 April 2015. She had been urgently referred to Mental Health Services by her GP, requesting that she be seen within 24 hours, but she was not seen before her death. The principal concern was the lack of an intermediate referral option between four hours and within five days, and the absence of contact within the requested 24-hour period.

Robert Leigh · Prevention of Future Deaths report View report

25 Sep 2023 Manchester West A. Walsh

Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.

Joan Hoggett · Prevention of Future Deaths report View report

12 May 2022 Sunderland D. Winter

Joan Hoggett died in Sunderland Royal Hospital on 5 September 2018 after being attacked and stabbed multiple times at her place of work. Concerns included insufficient engagement by the Mental Health Trust with the perpetrator’s family, missed opportunities for more proactive engagement, and challenges associated with staff capacity and absence.