2,023 reports
Information drawn from published reports and official responses.
Kallum Josh REED died after being found fully suspended during a police search following his disappearance on 11 February 2025. The report raises concerns about delays in autism spectrum disorder and ADHD referrals, assessments and diagnoses, and about crisis-care referral pathways and coordination between mental health services.
Department of Health and Social CareWest London NHS Trust
Jagjeet Singh, who had a history of intravenous substance misuse and mental and physical health problems, injected heroin after leaving hospital and was found deceased the following day with a syringe nearby. The inquest concluded that the death was drug related, with acute respiratory depression and fatal morphine and methadone toxicity identified as causes. The report raised concerns about the lack of an available mental health bed after medical-ward admissions, resulting in temporary accommodation, eviction and at least one night sleeping rough.
Department of Health and Social CareNHS England
Miss Samiyo Sahra Shih Farah, who had depression and a history of self-harm, was found unresponsive with a ligature around her neck on 30 December 2012 and was pronounced dead. The principal concerns were the lack of national guidance on observation of children and adolescents in specialist mental health units, inadequate formal protocols for communication during transfers between private and NHS providers, and inconsistent referral arrangements following her attendances at A&E.
Affinity Healthcare LimitedDepartment of Health and Social CareGreater Manchester Mental Health NHS Foundation TrustManchester University NHS Foundation TrustRoyal College of Psychiatrists
Marta Elena Vento was working alone as a hotel receptionist in Bournemouth when she was fatally beaten in an unprovoked attack on 9 December 2020. The report raises concerns about the sharing of remand prisoners’ risk information with sentencing courts, continuity of mental healthcare after release from prison, risk assessment of violent offenders managed by MOSOVO units, and access to patient information through the National Record Locator.
College of PolicingHM Prison and Probation ServiceNational Police Chiefs’ CouncilNHS Dorset Integrated Care BoardNHS England
Emma Carpenter was treated as an outpatient by child and adolescent mental health services from February 2004 to November 2006 and died from multi-organ failure caused by severe anorexia nervosa. The report identified insufficient physical-health monitoring, lack of specialist paediatric or physician input, and delay in accessing effective inpatient treatment as concerns.
Department for EducationDepartment of Health and Social CareDoncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustNHS England
Resmije Ahmetaj, also known as Merita Brahimi, died on 30 June 2024 from a traumatic head injury after falling from a height at a multi-storey car park while suffering an exacerbation of psychosis. The report identifies concerns about subtherapeutic antipsychotic medication levels not being acted on, communication and escalation within the mental health team, incomplete record-keeping, medication prescribing confusion, and safety mitigation on the car park’s penultimate floor.
BTCM LimitedEssex Partnership University NHS Foundation Trust
The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.
Greater Manchester Mental Health NHS Foundation Trust
Andrew Peter Wells, who had anxiety and depression and had repeatedly expressed suicidal thoughts and attempted suicide during a psychiatric admission, left the unit on 27 December 2018. He was later found hanging from a tree, suffered a severe hypoxic brain injury, and died in hospital on 31 December 2018. Concerns included the robustness of the Trust’s root cause analysis process and the inappropriate application of the Mental Health Act, including decisions about detention and observation levels.
Midlands Partnership University NHS Foundation Trust
Emmett Alexander Gillah had a history of mental illness and was discharged from mental health services at his own request. He later moved onto railway tracks and died after being struck by a train. Concerns included inadequate discharge information and follow-up arrangements, insufficient communication with his family and GP, and failures to refer him to mental health services when his mental health deteriorated.
Kent and Medway Mental Health NHS Trust
Timothy Thomas Reading died on 9 January 2025. He had a history of mental illness and had been discharged from inpatient care into the community under a community treatment order. The report identified the absence of a formal documented section 117 support plan, slow and disjointed transition arrangements, and no handover between responsible clinicians; the inquest concluded that he died by suicide, with hanging recorded as the medical cause of death.
Birmingham and Solihull Mental Health NHS Foundation TrustNHS England
Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.
Betsi Cadwaladr University LHBElysium Healthcare Limited
Stephen Peter Jackson was found deceased at home on 11 August 2018 after sending his mother a text message saying “sorry”; drugs paraphernalia and a suicide note were present, and the provisional cause of death was a diamorphine overdose. The report raised concerns that he was not seen by mental health clinicians after his GP requested an urgent appointment, despite reported low mood and negative thoughts, and that delays and possible under-funding of mental health services posed a risk of future deaths.
NHS Birmingham and Solihull Integrated Care BoardNHS England
Nicholas Spooner had a long-standing dual diagnosis of mental ill health and polysubstance abuse and was moved to Brighton for his own safety. He fell from the window of his third-floor room after removing the window restrictors, sustaining multiple potentially survivable injuries, and later died directly as a result of COVID-19 pneumonitis. The principal concern was the need for specialist dual-diagnosis services, including outreach, drop-in and day-centre support for people experiencing mental health crises entwined with substance abuse.
Brighton and Hove City CouncilChange, Grow, LiveDepartment of Health and Social CareNHS Surrey and Sussex Integrated Care BoardSussex Partnership NHS Foundation Trust
Jason Pulman, aged 15, was found dead on 19 April 2022 and the inquest concluded that he died by suicide, by hanging. Evidence indicated that he had not received specialist gender dysphoria treatment while waiting for GIDS and was awaiting further CAMHS assessment. The principal concern was that unclear referral mechanisms and inadequate resources for mental health support during waits for gender services could lead to similar circumstances recurring.
National Referral Support ServiceNHS England
Elizabeth Anne Watson attended the Humber Bridge on 5 December 2022 and jumped from it, landing on Cliff Road; she was declared dead at the scene. The concerns included a lack of structured training, including input from trained mental-health professionals, for bridge security staff identifying and responding to people in mental-health distress, as well as delays in emergency and mental-health support responses.
Humber Bridge Board
Steven Clive Cooke died at his home on 9 July 2019 after hanging himself by a ligature fashioned from a grey wiring cable. The principal concern was the absence of national guidance on engaging with the families of mental health patients to obtain as full a picture as possible.
NHS England
Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.
Department of Health and Social CareGreater Manchester Health and Social Care Partnership
Lee Purkis, aged 54, was found in an advanced state of decomposition on the floor of his home on 9 March 2023, having been there for up to two months; the cause of death was unascertainable. Before his death, he was subject to a mental health treatment requirement, but the receiving Trust was not informed of it and discharged him without learning about it. The report identifies a risk that failures to transfer or oversee such requirements could affect their proper administration in other cases.
HM Prison and Probation ServiceProbation Service
David Alan Price had a long history of alcohol use to cope with mental health difficulties and was found at home on 12 November 2018. The inquest heard that he would have benefited from an integrated mental health counselling and detoxification service, which was not available in Stockport.
NHS Greater Manchester Integrated Care Board
Becca was found hanging in her flat on 20 November 2023 after police forced entry following concerns raised by a colleague; the postmortem concluded that her death was due to hanging, and the inquest concluded suicide. The report identified an ongoing risk arising from the lack of a dedicated, named care co-ordinator during prolonged planned leave, including a period of approximately nine weeks before Becca’s death.
Norfolk and Suffolk NHS Foundation Trust
