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Matthew John Evans · Prevention of Future Deaths report View report

18 May 2022 Surrey K. Henderson

Matthew John Evans was a 47-year-old man who developed insomnia, anxiety and depression during the third COVID-19 lockdown and died on 16 June 2021 after ending his life. The principal concerns related to the GP’s lack of mental-health assessment, suicide-risk assessment, follow-up and consideration of referral; the general practice’s prescribing, communication and clinical-governance arrangements; and TalkPlus’s lack of clear guidance on referral to secondary mental-health services.

Jai SINGH · Prevention of Future Deaths report View report

15 Mar 2023 Birmingham and Solihull E. Brown

Jai Singh died at City Hospital on 28 January 2022 after being found in cardiac arrest in his cell at HMP Birmingham, having asphyxiated after placing a bag over his head. The report identifies repeated failures to communicate and record family and clinical concerns, use interpreters, assess risk, operate the ACCT process, and provide appropriate mental-health admission and transfer. It also identifies ongoing risks from the absence of a psychiatrist in the prison mental-health MDT and the lack of ongoing risk-assessment documentation in SystemOne.

Gurdeep Singh Dundhal · Prevention of Future Deaths report View report

10 Sep 2019 Birmingham and Solihull L. Hunt

Gurdeep Singh Dundhal, who had paranoid schizophrenia and used illicit substances, died after jumping from the fifth storey of a car park on 27 April 2019; he passed away in hospital on 28 April 2019. The concerns included delays and resource problems in arranging a mental health assessment, missing information during the assessment, the decision to use section 2 rather than the recommended section 3, and failure to investigate and learn lessons across agencies.

Carl Robert ELLSON · Prevention of Future Deaths report View report

20 Dec 2022 Birmingham and Solihull L. Hunt

Carl Robert ELLSON was found deceased in a wooded area on 16 July 2022 after sustaining a fatal self-inflicted wound. He had been experiencing anxiety and insomnia and had presented with suicidal ideation shortly before his death. The concerns identified were that GP access to urgent mental health reviews was unclear and unsafe, that patients in crisis were expected to initiate contact with mental health practitioners, and that GPs were not fully aware of how to request an urgent psychiatric review.

Jonathan Anthony MEANEY · Prevention of Future Deaths report View report

24 Aug 2017 Inner North London M. Hassell

Jonathan Anthony Meaney took an overdose on 13 March 2017 and was assessed at hospital, where inpatient treatment was recommended but no bed was found. He was discharged on 15 March after expressing a wish to leave and took his own life the following day; his medical cause of death was morphine and alcohol toxicity. Concerns included the prolonged wait for a bed, aspects of the pre-discharge mental health assessment, lack of consultation with another team member, and uncertainty about whether a proposed GP referral was made.

Miles Benedict Abel · Prevention of Future Deaths report View report

29 Jul 2016 Wiltshire and Swindon I. Singleton

On 14 January 2016, Miles Benedict Abel died after placing a ligature around his neck while at home. The concerns related to the referral process from a GP surgery to the Community Mental Health Team, including the absence of an audit trail confirming that referral faxes were sent and inconsistent follow-up calls to check receipt.

THOMAS JEFFERY KING · Prevention of Future Deaths report View report

15 Oct 2020 Essex L. Brookes

Thomas Jeffery King was found hanging at his home on 28 April 2020, and his death was confirmed at the scene. The inquest concluded that he had intentionally ended his own life while experiencing very low mood and a history of poor mental health. The principal concern was that the Health and Justice Team used software that could not be accessed by other relevant mental health teams, meaning important information about crises and risks could be unavailable when assessing and managing a person.

Juan David Martin · Prevention of Future Deaths report View report

11 Jun 2024 Inner West London P. Malhotra

Juan David Martin, who had been detained under the Mental Health Act and was awaiting an appropriate mental health bed, was evacuated from a hospital assessment suite during a fire alarm and ran away. He was later witnessed allowing himself to fall from height and was confirmed deceased on 13 April 2022. The principal concern was that inadequate mental health bed capacity in London created a genuine risk of future deaths.

Dominic Adam Travis · Prevention of Future Deaths report View report

7 Dec 2016 Manchester (North) L. Hashmi

Dominic Adam Travis, an 18-year-old man with mental health problems and regular use of cannabis and other substances, died in hospital on 18 May 2015 after suffering catastrophic injuries when he fell or jumped from a derelict mill following an acute psychotic deterioration and absconding from supported accommodation. The concerns raised included whether specialist inpatient provision adequately met the needs of young adults with mental health problems and whether the NHS Trust’s investigation into his care was sufficiently independent, transparent and timely.

Ian Michael Cockfield · Prevention of Future Deaths report View report

25 May 2022 East London G. Irvine

Ian Michael Cockfield died in hospital on 12 July 2021 after collapsing and sustaining a cardiac arrest despite resuscitative efforts. The report raised concern that, after transfer to a mental health ward, his falls risk assessment was not reviewed and he subsequently fell while mobilising unsupervised, sustaining a serious head laceration.

Madeleine Eve SAVORY · Prevention of Future Deaths report View report

15 Nov 2023 Suffolk D. Stewart

Madeleine Savory, aged 15, died on 26 February 2022 after being found ligatured in a bathroom on Bergholt Ward at Ipswich Hospital, following a period during which their whereabouts were unknown. The substantive concerns included the availability of Tier 4 paediatric mental health beds, failures in risk assessment and communication, ward staff understanding of risk, and the implementation of a school safety plan.

Sailor (previously known as Sara) COURT · Prevention of Future Deaths report View report

10 Jun 2024 South London S. Naughton

Sailor (previously known as Sara) COURT, aged 14, died by suicide on 17 September 2021 after taking an overdose at home while on the CAMHS waiting list for treatment. The principal concerns were unacceptably long waits for assessment and treatment, which had not improved and were attributed to insufficient resources relative to demand.

Thiago Araujo · Prevention of Future Deaths report View report

29 Jan 2020 East London G. Irvine

Thiago Araujo was found deceased at his mother’s shared address on 5 February 2020 after deliberately ingesting a substance. He had been receiving community psychiatric care and had disengaged from crisis-team support. Concerns included the closure of his crisis-team referral without arrangements to address identified risks, inaction after an acute suicide risk was identified, and the lack of a process for his family to escalate concerns about delivery of a potentially harmful package.

Ms Aleksandra Markowska · Prevention of Future Deaths report View report

29 Sep 2022 East London N. Persaud

Ms Aleksandra Markowska was found unresponsive on 30 September 2021 after jumping from 21 Gardner Close, and her death was pronounced at the scene. The inquest concluded that she took her own life while suffering from pregnancy-related depression and anxiety, after seeking help but not receiving a review by a perinatal psychiatrist. The principal concern was the lack of direct access for BPAS patients experiencing pregnancy-related mental health decline to perinatal psychiatry teams.

Lee Joseph Hastings Swain · Prevention of Future Deaths report View report

16 Jun 2017 Liverpool and the Wirral A. Bhardwaj

Lee Joseph Hastings-Swain, aged 28, was found deceased hanging from a bannister at his home on 30 November 2016. The inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included inadequate coordination and information-sharing between mental health services, delays in referral, poor clinical records, and insufficiently proactive engagement after his transfer between NHS trusts.

OSKAR MILES NASH · Prevention of Future Deaths report View report

31 Jan 2022 Surrey R. Travers

Oskar Nash was 14 when he died by suicide on 9 January 2020 after a history of autism, anxiety, suicidal ideation and self-harm. The report identified failures including the lack of clinical mental-health assessment and support, an inappropriate mainstream-school placement, inadequate information in his Education, Health and Care Plan, and failures by children’s services to assess and respond to his risks. The report also raised ongoing concerns about autism training, referral triage, information sharing, safeguarding guidance and post-death investigations.

Michelle Louise WHITEHEAD · Prevention of Future Deaths report View report

4 Oct 2023 Nottinghamshire L. Bower

Michelle Louise Whitehead died on 7 May 2021 while an inpatient, after acute hyponatraemia caused by psychogenic polydipsia. The report identified failures to follow the Rapid Tranquilisation policy, including inadequate monitoring of consciousness and delays in responding to her deterioration, and raised concerns about staff training, policy clarity, monitoring guidance, and the detection and management of psychogenic polydipsia.

Daniel Maher · Prevention of Future Deaths report View report

18 Apr 2017 Surrey A. Crawford

Daniel Maher was found hanging at his home on 26 May 2016, and efforts to resuscitate him were unsuccessful. The report raised concerns that significant information about vulnerable individuals may not be readily accessible when mental health services in West Sussex and Surrey are involved, including because of limited access to records and reliance on verbal referrals without routinely shared paperwork.

Katharine Mary DOWLING · Prevention of Future Deaths report View report

14 Mar 2019 Cheshire A. Moore

Katharine Mary Dowling, who had autism spectrum disorder and co-existing mental health issues, self-ligatured while receiving care on an acute psychiatric ward and died in hospital. The concerns included inadequate integration of autism into care planning, insufficient autism training and specialist input, an inappropriate ward environment, inconsistent observations, and wider variation in national guidance and support.

Charley Ann Patterson · Prevention of Future Deaths report View report

19 Oct 2022 North and South Northumberland A. Hetherington

Charley Ann Patterson had experienced low mood, anxiety, bullying and previous self-harm. She attended hospital for support in May 2020, but the planned referral to the Northumberland (Early Help) Hub was not made and there was an absence of communication with other services and professionals. She later died by suicide on 1 October 2020. The concerns included increased demand for children’s mental health support following the Coronavirus pandemic and delays in receiving treatment and early support.