2,023 reports
Information drawn from published reports and official responses.
David Sean Read collapsed after injecting heroin on 1 July 2016 and died in hospital on 3 July 2016. Concerns were raised about the handling and timing of his Community Mental Health Team appointments, including that a replacement appointment was scheduled more than 16 weeks after re-referral, during which time he died.
Norfolk and Suffolk NHS Foundation Trust
Natalie Gray died after leaving Priority House, where she was an informal patient, and jumping in front of a train at Barming railway station on 21 April 2015. The principal concerns included insufficient risk assessments, inadequate handovers and failures in procedures for informal patient leave, communication of risk, recording third-party information and reporting her absence to police.
Kent and Medway Mental Health NHS TrustNHS Kent and Medway Integrated Care Board
Mr Sam Spooner died at Leighton Hospital on 31 August 2018 after being found unresponsive following an act intended to end his life. The report identified concerns about inadequate multi-agency information sharing, coordination and intervention despite known suicide risk, and excessive reliance on his family to keep him safe.
CounsellorRope Green Medical Centre
Samuel Alexander Morgan, who was suffering from alcohol addiction and had diagnoses of ADHD and social anxiety, was found deceased at his parents’ house on 9 May 2019 after tying a ligature around his neck. The principal concern was that addiction and mental health services could not electronically access each other’s records, meaning important information about suicide risk and patient safety might be lost or insufficiently understood between treating teams.
Swansea Bay University Local Health Board
Evie Jane Davies was found deceased at home on 2 December 2021 after taking a significant overdose of medication that had not been prescribed to her. The report states that this was likely a deliberate act intended to end her life, amid deteriorating mental health and significant personal stressors. The principal concern was insufficient real-time information sharing between the café71 crisis service, the mental health team and the GP, potentially preventing prompt follow-up of people at risk.
Cheshire and Wirral Partnership NHS Foundation TrustNHS Cheshire and Merseyside Integrated Care BoardSpider Project Café71
On 2 June 2010, Andrew David Cairns entered Rachael Claire Slack’s home, stabbed their son Auden George Slack and Rachael Slack to death, and then stabbed himself to death. The principal concerns were failures in information-sharing between Police and Mental Health Services, and failures to communicate the assessed risk and safety measures to Rachael regarding the threat posed by Andrew.
Department of Health and Social CareDerbyshire ConstabularyDerbyshire Healthcare NHS Foundation TrustHome OfficeNational Police Chiefs’ Council
Mrs Wanda Stachurska was found deceased on 18 November 2014 after being discharged from hospital the previous evening following a suicide attempt involving an overdose and attempted hanging. Concerns included the quality of the mental health risk assessment, including the use of an untrained security guard as an interpreter and the failure to communicate relevant information about the earlier attempted hanging. The report also raised concerns that neither Trust conducted a serious incident review after her death.
Surrey and Borders Partnership NHS Foundation TrustSurrey and Sussex Healthcare NHS Trust
Alexander Channing, known as Alec, was found suspended by a ligature in his university halls of residence on 27 January 2022 and was pronounced dead at the scene. The report records concerns about delays in transferring his mental health care, discharge planning without Home Treatment Team involvement, postponed assessment, limited proactive attempts to obtain consent to share information, and a lack of relevant training and policies.
Arts University BournemouthDevon Partnership NHS TrustDorset Healthcare University NHS Foundation Trust
Jason Lennon, a 37-year-old man living in supported accommodation, died on 31 July 2019 after being found unresponsive while restrained in a prone position by security officers at the Excel Centre; resuscitation efforts later ceased in hospital. The concerns included failures in community mental health care, including inadequate monitoring, assessment, communication and documentation, and the extent and manner of the restraint used by security officers. The report also identified deficiencies in the Trust’s serious incident action plan and uncertainty about whether regulatory referral had been considered.
Department of Health and Social CareEast London NHS Foundation TrustNHS England
Christopher Thomas Ace Ryan was detained under section 3 of the Mental Health Act and absconded from escorted leave on 23 December 2020. He obtained and smoked heroin, developed laboured breathing, lost consciousness, and died despite CPR. Concerns included repeated absconding during escorted leave, access to illicit drugs, unclear boundaries around escorted leave, and the security and smoking arrangements at the hospital car park.
South West London and St George'S Mental Health NHS Trust
On 1 May 2013, May Stokoe was fatally attacked with a knife and James Henderson Stokoe inflicted fatal knife injuries on himself. The report raised concerns about the assessment and involvement of carers or partners in mental health services, including whether their information could better inform risk assessments and whether domestic abuse involving older people might be missed.
Department of Health and Social Care
On 26 January 2015, Jacqueline Williams was taken to Royal Blackburn Hospital and assessed as being at moderate risk of self-harm, but a referral to the Mental Health Liaison Team was not accepted because of a communication breakdown. She subsequently hanged herself in an emergency department cubicle; concerns related to referral errors and systems that did not make missed or unaccepted referrals readily identifiable and rectifiable.
East Lancashire Hospitals NHS TrustLancashire & South Cumbria NHS Foundation Trust
Evelina Vilkiene, who was receiving mental health services, was found hanging at her home on 7 June 2022 and was pronounced dead at the scene. The report identified concerns about the absence of detailed risk assessments and jointly agreed risk-management plans during care transitions and when clonazepam was reduced, as well as the lack of subsequent care-coordinator reviews.
North East London NHS Foundation Trust
Zachary KLEMENT was found suspended in the bedroom of his supported accommodation on 2 March 2021 and was pronounced deceased by attending paramedics. The report raised concerns about the lack of mental health care and therapies tailored to people with neurodiverse conditions, including the absence of suitable inpatient options, limited continuity from Home Treatment Teams, and the limited availability of psychological interventions.
NHS England
Vincenzo Joseph Michael LIPPOLIS, aged 21, died on 1 November 2021 after being found hanging in woodland at Sand Dunes, Mablethorpe. Concerns were raised about why he was not admitted under the Mental Health Act after a recent suicide attempt and why a recommended face-to-face assessment was replaced by a telephone call, after which the case was closed the same day.
LPFT Legal ServicesNAViGO Health and Social Care CICRecipient name withheld
Toby Peter Edward Nieland had a complex Dual Diagnosis, chronic pancreatitis with persistent pain, opiate addiction, and a history of self-harm and suicide attempts. After discharge from inpatient care in April 2018, he was found collapsed and unresponsive on 17 May 2018 after self-suspending himself by a belt in his room. The report identified concerns about failures to communicate family warnings, inadequate coordination and care planning, insufficient monitoring and assertive outreach, and gaps in services for people with Dual Diagnosis.
Lincolnshire County CouncilLincolnshire Partnership NHS Foundation TrustNHS Lincolnshire Integrated Care BoardWithYou
James Paul Michael Masheter died by hanging at his home on 1 April 2024, after experiencing a significant mental health crisis and making calls for ambulance assistance. The report raises concerns that existing NHS Pathways mental health triage may not properly risk-assess serious crises involving a risk to life, and that categorisation as category 3 contributed to significant delays in ambulance attendance. Incorrect information about the expected waiting time was also provided to his friend, who believed the ambulance was arriving imminently and left him.
NHS Pathways
Shaun Daniel Houghton was found dead in a rural area on 1 December 2022 after self-discharging from Atherleigh Park Hospital against medical advice the previous day. During the inquest, concerns were raised about self-discharge procedures, including the absence of routine referral to a Consultant or Senior Doctor, the lack of a checklist for junior doctors, and medication not being prescribed or dispensed at discharge.
Greater Manchester Mental Health NHS Foundation Trust
Kieran Joseph Kevan Crimmins took his own life after discharge from the Crisis and Home Treatment Team, in circumstances where the report found ongoing psychiatric monitoring and support would have been appropriate. The principal concerns were incomplete or inaccurately recorded actions, the way significant information was communicated to him, and apparent gaps in routes back into mental health services and communication between providers.
Hywel Dda University LHB
David Knight, who was detained under the Mental Health Act for chronic mental health issues, died on 23 May 2015 after walking onto a railway track in front of an oncoming train while on Section 17 leave. Concerns included a limited risk assessment before leave, no notification to local community and home treatment teams, and the difficulties associated with his out-of-county placement, including reduced family involvement and communication challenges.
Department of Health and Social CareNHS England
