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Edward England Rhodes · Prevention of Future Deaths report View report

1 Aug 2023 Dorset R. Middleton

Edward England Rhodes, who had a history of alcohol misuse, relapsed after a period of abstinence and was found unresponsive on 17 November 2022. Toxicology revealed methadone at a level consistent with severe, possibly fatal toxicity, and the inquest recorded a drug-related death. Concerns included a possible breakdown or misunderstanding between Mr Rhodes and his GP about the steps required for a mental health referral, and the absence of clear written confirmation of respective responsibilities.

Marion Joanne Turner · Prevention of Future Deaths report View report

25 Jun 2014 Essex C. Beasley-Murray

Marion Joanne Turner, aged 40, was found hanging at her home on 18 January 2013. A concern was raised that a solicitor’s message about concerns for her mental health was left unread in a pigeon hole until the following day.

Jonathan Mark George Hamer · Prevention of Future Deaths report View report

10 Apr 2025 West London L. Brown

Jonathan Mark George Hamer, who had bipolar affective disorder and was receiving community mental health care, died by suicide on 24 April 2024 after going onto railway tracks in front of a train. Concerns included communication failures during care-coordinator absences, the lack of systems to redirect or action unanswered communications, and the failure to prioritise and regularly review his case.

David John Buttriss · Prevention of Future Deaths report View report

12 Jan 2018 Cornwall and Isles of Scilly E. Carlyon

David John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health teams.

Nancy Hughes · Prevention of Future Deaths report View report

12 Jun 2015 North Wales (East and Central) J. Gittins

Nancy Hughes, who had Alzheimer’s disease and was receiving Risperidone, fell at a care home and later suffered a further unwitnessed fall in hospital before dying on 3 January 2014. The concerns were that her medication was not reviewed as required and that there was insufficient cohesion between mental health and medical treatment, potentially affecting care for vulnerable patients.

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 on 14 October 2020, after police encountered him undressed by the roadside while his partner was trying to take him to hospital. The report raised concerns that police did not detain him under section 136 of the Mental Health Act for assessment and that officers had limited access to qualified, clinically informed mental health advice and records when responding to community mental health crises.

Nathan Tesla George Scantlebury · Prevention of Future Deaths report View report

23 Jul 2024 Cheshire C. Keighley

Nathan Scantlebury, aged 16, died in hospital shortly after being found unresponsive with a ████████ tight around his neck on 25 September 2019. The principal concerns were the lack of suitable placements for children with complex mental health needs and failures relating to the suitability and management of his placement and care arrangements.

Samuel Alban Stanley · Prevention of Future Deaths report View report

12 Mar 2022 North East Kent C. Wood

Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.

Nicolette Elizabeth McCARTHY · Prevention of Future Deaths report View report

22 Nov 2024 East Sussex M. Spencer

Nicolette Elizabeth McCarthy was detained in a secure mental health unit after attempts to take her life and remained at risk of suicide. On 19 September 2023, she failed to return from a short period of leave and was not promptly treated as absent without leave; the inquest identified failures in systems and procedures intended to ensure her safety. The report raises concerns that smoke-free policies and unclear guidance may increase the risk of self-harm or suicide for mental health patients on unescorted leave.

David Richard Fowler · Prevention of Future Deaths report View report

20 Dec 2019 Manchester (West) R. Galloway

David Richard Fowler, who had a significant history of mental illness, substance misuse and a brain injury, died after falling from a motorway bridge on 26 December 2018 with the intention of ending his life. Eight days earlier, his detention under section 3 of the Mental Health Act 1983 was removed without a community plan or legal framework. The report identified concerns that his family was not invited to the relevant meeting or consulted, and that there was confusion about responsibility for informing family members.

Sean Daniel FEGAN · Prevention of Future Deaths report View report

25 Mar 2021 Nottinghamshire G. Clow

Sean Daniel Fegan, who had autism, complex mental health conditions and drug misuse, died from toxicity after taking a combination of prescribed and illicit substances on or before 26 April 2020. The report raised concerns about decisions regarding secondary mental health care, access to treatment, dual diagnosis services, liaison with family members, implementation of care plans and autism awareness.

Bituin Pizzaro Pimlott · Prevention of Future Deaths report View report

6 Sep 2021 Manchester South A. Mutch

Bituin Pizzaro Pimlott was found suspended from a ligature at the garage of her home on 22 February 2021. The inquest heard that she had been struggling with her mental health and that telephone consultations were used instead of face-to-face appointments during the pandemic. Concerns included the lack of referral by her GP practice to the crisis team and uncertainty about the guidance for making such referrals.

Barry Thraves · Prevention of Future Deaths report View report

26 Oct 2015 Leicester City and South Leicestershire L. Brown

Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.

Mr Benjamin Sulzbacher · Prevention of Future Deaths report View report

15 May 2024 Manchester North J. Kearsley

Mr Benjamin Sulzbacher had experienced deteriorating mental health and was admitted to a private hospital after attempting to tie a ligature at home. After discharge, no referral was made to the NHS Home Based Treatment Team, and he died after tying a ligature on 27 September 2023. Concerns included uncertainty among services about NHS discharge support for private inpatients and a lack of understanding at the Priory about the community services available.

Jack Mathew Peatling · Prevention of Future Deaths report View report

13 Oct 2025 Essex S. Horstead

Jack Mathew Peatling, who had a very high risk of suicide, made further serious suicide attempts and was assessed as requiring urgent inpatient mental health care. No suitable inpatient bed was available for six days, during which he was managed in the community despite clinical recognition that his risk could not be safely managed there; he died by suicide on 5 June 2023. The report identified the chronic lack of available high-risk mental health inpatient beds as a principal concern.

Kaine Regan FLETCHER · Prevention of Future Deaths report View report

25 Jul 2025 South Yorkshire (Western) A. Pountney

Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.

Fadhia SEGULEH · Prevention of Future Deaths report View report

27 Aug 2021 Manchester South A. Mutch

Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.

Paul Christopher REEVES · Prevention of Future Deaths report View report

12 May 2025 Inner North London I. Potter

Paul Christopher Reeves died in hospital on 9 April 2024 after ingesting and aspirating mud following the use of unknown drugs or psychoactive substances, and suffering a cardiac arrest during re-intubation. The principal concerns related to inadequate communication between his supported accommodation and mental health team, uncertainty about staff responsibilities, escalation of concerns about his deteriorating condition, and staff knowledge, skills or training in responding to his behaviour in the community.

Sean Christopher Seabourne · Prevention of Future Deaths report View report

17 Dec 2013 Worcestershire G. Williams

Sean Christopher Seabourne, who had recurrent depression and anxiety, sought help from his GP and mental health services in August 2013. On 1 September 2013, he hanged himself at his place of work in Redditch. The report identified concerns about communication and unclear roles between mental health teams, including the failure to ensure that information about his high risk and settled plans to kill himself was formally documented and shared.

Hannah Louise Booth · Prevention of Future Deaths report View report

9 Dec 2025 Derby and Derbyshire S. Evans

Hannah Louise Booth, who had been diagnosed with post-natal depression after giving birth in July 2024, drowned in the Goyt River on 6 January 2025 after sending a message evidencing her intention to take her own life. The report identified concerns about information sharing between services, including different record systems, incomplete records, and relevant information about Hannah being recorded only in her baby’s records. Increasing contact about her baby’s development was not shared with perinatal mental health services or recognised as potentially indicating that Hannah was struggling.