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PAUL HILLS · Prevention of Future Deaths report View report

19 Nov 2020 North East Kent S. Hayes

Paul Hills was found deceased at home in his garage on 24 April 2020 after suspending himself from a rafter. He had a history of post-traumatic stress disorder, reported episodes and dry runs of self-harm, and was receiving treatment. Concerns included inadequate risk assessment and care-plan updates, failure to document or share escalating risk information, insufficient planning for remote treatment during the COVID-19 pandemic, and limitations affecting local treatment and communication.

Shahzadi Khan · Prevention of Future Deaths report View report

29 Jan 2024 Manchester South A. Mutch

Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.

Nicolas Gerasimidis · Prevention of Future Deaths report View report

30 Jan 2024 Cornwall and Isles of Scilly A. Cox

Nicolas Gerasimidis had a history of mental illness manifesting as OCD and anxiety, which deteriorated despite referrals and treatment arrangements. He was found hanged at his home address on 3 June 2023, and the inquest recorded a conclusion of suicide. Concerns included community mental health referrals being rejected, shortages of care coordinators and consultants, a one-year waiting list for psychological treatment, lack of hospital bed availability, and shortcomings in information provided to his family.

Rodney John DIXON · Prevention of Future Deaths report View report

21 Jun 2021 East Sussex J. Healy-Pratt

Rodney John Dixon took his own life at home in Eastbourne on 15 July 2019 during the course of a Mental Health Act Assessment, following deterioration in his mental and physical health. The report raised concerns that training on Mental Health Act assessments, patient risk management and assessors was sub-optimal, and that independent clinicians needed reasonable access to patient data before assessments.

Finnian Gabriel Denney Kitson · Prevention of Future Deaths report View report

27 Jan 2022 Manchester City Z. Golombeck

Finnian Gabriel Denney Kitson, who had been diagnosed with anxiety and prescribed medication, took his own life in student accommodation on 8 October 2020, shortly after commencing studies at The University of Manchester. The report’s principal concern was that the UCAS application process did not refer separately and explicitly to mental health illness, which could discourage applicants from disclosing diagnoses and limit access to support when starting university.

Nicholas Patrick SULLIVAN · Prevention of Future Deaths report View report

22 Aug 2016 Manchester City N. Meadows

Nicholas Patrick SULLIVAN, who had a chronic mental illness and was experiencing suicidal ideation and auditory hallucinations, attended an emergency department but was not triaged or referred for a timely mental health assessment. He left after waiting, later reiterated that he was suicidal, ran into a road and was struck by a car, dying from his injuries on 30 November 2014. The principal concerns included failures to record mental health risks at reception, trigger urgent triage and safeguarding, activate escalation procedures, and ensure appropriate coordination and staffing.

David Ian Hamilton · Prevention of Future Deaths report View report

5 Jun 2017 Manchester South A. Mutch

David Ian Hamilton developed insomnia in October 2016, sought help from healthcare services, and was prescribed mirtazapine. He became increasingly anxious and reported thoughts of self-harm before being found dead at home on 7 February 2017; the investigation concluded that the death was suicide. Concerns included limited information-sharing between health professionals, unclear referral and escalation processes, lack of referral to sleep clinic services, and insufficient documentation of therapy selection.

Callum Wong · Prevention of Future Deaths report View report

3 May 2023 North London P. Straker

Callum Wong was found having hanged himself on 27 August 2022. The report raised concern about considering exceptions to patient confidentiality in cases of mental ill health where informing third parties could provide crucial non-medical support.

Amina Ahmed Ismail · Prevention of Future Deaths report View report

14 Jun 2024 Manchester South A. Bridgman

Amina Ahmed Ismail, aged 19, died on 15 September 2023 at Pankhurst Ward, Priory Hospital Cheadle, after self-ligaturing; the medical cause of death was ligature strangulation. The report describes her prolonged stay in a PICU, deterioration in her mental health, shortages of appropriate specialist care beds, and delays in arranging and funding a suitable placement as concerns contributing to the circumstances of her death.

Patricia Genders · Prevention of Future Deaths report View report

28 Oct 2025 West Sussex, Brighton and Hove N. Armstrong

Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.

Mr Paz Ogbe-Millar · Prevention of Future Deaths report View report

5 Feb 2024 North London T. Murphy

Mr Paz Ogbe-Millar died on 2 December 2021 after jumping in front of a high-speed train at Harrow and Wealdstone station, during a relapse in cannabis-induced psychosis. Concerns included his discharge from community mental health services, inadequate recording of police information about his self-harm risk, not allowing his mother to remain with him in the Emergency Department, referral-system problems, and insufficient observation arrangements for mental health patients awaiting assessment.

Brooke MARTIN · Prevention of Future Deaths report View report

2 Jul 2021 Milton Keynes T. Osborne

Brooke Martin was detained under the Mental Health Act at Isla House, where she was found hanging in her room on 11 June 2019 after earlier ligature-related incidents and concerns about observation and risk assessment. She died at Milton Keynes University Hospital. A principal concern was that incompatible NHS record systems prevented healthcare providers from accessing complete patient records, including information from an out-of-area hospital.

Michael Sean Heath · Prevention of Future Deaths report View report

2 Oct 2024 Manchester South C. Murray

Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.

Felix Stefan CEMBROWICZ · Prevention of Future Deaths report View report

12 Sep 2013 Avon T. Moore

Felix Stefan CEMBROWICZ was found hanging after deterioration in his mental health while awaiting a planned mental health assessment, was admitted to Bristol Royal Infirmary, and subsequently died. The report raised concerns that the electronic Rio record system did not transfer important records, including relapse management plans, for some discharged patients, potentially leaving staff unaware of relevant histories or delaying assessments.

PETER MARTIN AARON FLEMING · Prevention of Future Deaths report View report

14 Jul 2023 Birmingham and Solihull J. Bennett

Peter Martin Aaron Fleming was found deceased in his flat on 10 November 2022 after taking a deliberate overdose of prescribed medication; his cause of death was confirmed as carbamazepine toxicity and the conclusion was suicide. The report raised concerns about inadequate mental health resources, ineffective communication between specialist teams and health organisations, delays in medication provision, and shortcomings in medication management and monitoring.

Haydar Jefferies · Prevention of Future Deaths report View report

20 Dec 2024 Surrey C. Topping

Haydar Jefferies was detained at HMP Coldingley and developed severe depression and psychosis before self-ligaturing in his cell on 1 March 2023; he was resuscitated but died at hospital on 5 March 2023 from hypoxic brain injury and pneumonia. The principal concerns included failures to record and share risk-relevant information, refer him promptly to mental health services, provide an adequate mental health assessment and obtain appropriate clinical care and supervision during his acute deterioration.

Jonathan “Jonny” Philip Cole [JC] · Prevention of Future Deaths report View report

5 Jun 2023 Derby and Derbyshire S. Cartwright

Jonny Cole was found hanging at Old Stone Bridge, Butterley Park, on 9 August 2018, after having acted with the intention to end his life. He had PTSD, anxiety and suicidal ideation and was under the care of his local mental health trust. The report raised concerns about inadequate identification and management of his suicide risk, gaps in trauma treatment and veteran services, shortcomings in Ministry of Defence mental-health provision and compensation processes, and the robustness of the Trust’s investigation.

Oliver Davies · Prevention of Future Deaths report View report

11 Oct 2024 Worcestershire D. Reid

Oliver Davies died by suicide by hanging in his cell at HMP Hewell on 31 December 2022. The concerns included delayed and incomplete mental health assessment, failures to share relevant information about his self-harm and suicide risk, inadequate prioritisation and follow-up by the mental health care coordinator, and failures to keep him informed about healthcare and appointments.

Bradley Jordache Morgan · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Bradley Jordache Morgan was declared dead on 13 May 2018 after falling from the eighth-floor balcony of his home; the medical cause of death was multiple blunt injuries. He had a history of mental illness and was considered at high risk of suicide and self-harm, but was not reviewed by the community mental health team after a missed appointment. Concerns included communication and follow-up failures, excessive staff caseloads, and underfunding of mental health services creating a risk to life.

Mr Dean Bradley · Prevention of Future Deaths report View report

28 May 2025 Teesside and Hartlepool C. Bailey

Mr Dean Bradley was found deceased by hanging in his hostel flat on 15 October 2021, after earlier suicidal behaviour and expressions of paranoid and persecutory beliefs while apparently under the influence of drugs. Concerns included whether current resources adequately safeguard people with mental health concerns while intoxicated, and failures to contact mental health services and to relay the details of his crisis to hostel staff.