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Louise Elizabeth Amy Crane · Prevention of Future Deaths report View report

23 Jun 2025 Inner North London I. Potter

Louise Crane died at Highgate Mental Health Centre on 19 September 2024 from ligature compression to the neck while detained under section 3 of the Mental Health Act. The report identifies concerns about information sharing and recording, risk management, staffing and care and treatment on Topaz Ward, and notes a lack of a nationwide policy or approach to anti-ligature measures in mental health settings.

George Nigel Palmer · Prevention of Future Deaths report View report

15 Sep 2015 Surrey M. Fleming

George Nigel Palmer was found dead at his home on 7 April 2014, suspended from a belt attached to his bedroom door. He had a history of depression and anxiety and had received inpatient and community mental health support before being discharged after his perceived improvement and move to Durham. Concerns were raised about discharge follow-up mechanisms for patients moving to a different area and the appropriateness of follow-up letters when contact cannot be made.

Dean Martin Ford · Prevention of Future Deaths report View report

4 Dec 2024 East London N. Persaud

Dean Martin Ford died by suicide on 10 March 2024 after leaving home, buying a length of rope, and being found hanging in Bedfords Park, Romford. Concerns included failures by two mental health teams to carry out a holistic risk formulation, an incorrect assessment of his risk as low, and the absence of audits for risk assessments of people referred but not accepted by the mental health and wellbeing team.

Karen O’Brien · Prevention of Future Deaths report View report

15 Jul 2015 City of London R. Palmer

Karen O’Brien suffered from chronic pain and depression and had disclosed thoughts of self-harm. After a mental health referral, SEPT determined that a face-to-face assessment was not required; she later jumped into the path of an underground train, and the inquest concluded that she killed herself, with multiple injuries as the medical cause of death. The principal concerns were the lack of further inquiry or face-to-face assessment and the basis on which SEPT overrode the GP’s request, including its interpretation of NICE guidance.

Alex Ganski · Prevention of Future Deaths report View report

26 Mar 2026 West Sussex, Brighton and Hove J. Turner

Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.

Angela Dawn COLLINS · Prevention of Future Deaths report View report

4 Dec 2023 Bedfordshire and Luton E. Whitting

Angela Dawn COLLINS died after taking an overdose of prescription drugs while experiencing severe mental and emotional distress. The report describes limited or no support for vulnerable adults at risk of overdose or mental health crisis despite being under secondary mental health services, alongside missed or unsuccessful contacts before her death.

Margery Annie Astill · Prevention of Future Deaths report View report

11 Jul 2017 Leicester City and South Leicestershire L. Brown

Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations were completed.

Deidre Harvey · Prevention of Future Deaths report View report

8 Aug 2017 South Wales Central C. Woolley

Deidre Harvey died on 19 April 2017 after attaching a dressing gown cord to her neck in a mental health unit bathroom; the cause of death was recorded as hanging. The report raised concerns about coordination between mental-health and outside consultants, management of ligature risks and dangerous items, risk-assessment communication, and the potential toxicity and monitoring of hydroxychloroquine.

Victoria Anne TAYLOR · Prevention of Future Deaths report View report

5 Sep 2025 North Yorkshire and York C. Cundy

Victoria Anne Taylor’s mental health deteriorated between May and October 2024, involving suicidal ideation, self-harm and binge drinking. She was reported missing on 1 October 2024, and her body was recovered from the River Derwent on 22 October 2024. The principal concerns were that mental health services did not offer a treatment pathway addressing reported childhood trauma, provided limited safety planning, and did not suggest or convene a multi-agency approach despite knowing that several agencies were involved.

Stephen McDermott · Prevention of Future Deaths report View report

17 Mar 2017 Preston and West Lancashire C. Hammond

Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.

Yuksel Bedri ISMAIL · Prevention of Future Deaths report View report

25 Aug 2022 Bedfordshire and Luton E. Whitting

Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.

TERENCE TALBOT · Prevention of Future Deaths report View report

3 Dec 2021 Mid Kent and Medway S. Hayes

Terence Talbot died at Maidstone & Tunbridge Wells NHS Trust on 9 April 2020 from multiorgan failure due to empyema and pneumonia associated with DRESS Syndrome, following a severe reaction to prescribed medication for bipolar affective disorder. The concerns included repeated discharge and readmission, lack of formal mental-capacity assessments, insufficient dermatology review and emollient application, inadequate food and fluid leading to malnutrition, and issues concerning a requirement to attend in person to claim benefits while severely ill.

Anita Mandalia · Prevention of Future Deaths report View report

9 Jul 2021 East London G. Irvine

Anita Mandalia took an overdose of prescribed medications at home on 7 February 2021 and died in hospital on 11 February 2021 from complications of the overdose. Concerns included prescribing beyond recommended guidance, failure to re-refer her to mental health services when concerns arose, and prescribing pain medication that gave her access to an excess of medication despite overdose-risk mitigation measures.

Sophie Louise TOWLE · Prevention of Future Deaths report View report

24 Oct 2025 Nottinghamshire A. Poutney

Sophie Louise TOWLE died at Kings Mill Hospital on 27 May 2024 after suffering a large pulmonary embolus originating from a deep vein thrombosis in her left leg. The report describes concerns about the management of an inserted foreign object, VTE risk assessment and related policy and training, mental health services for patients with personality disorders, staffing levels, and cross-sector communication and working.

Georgia Sylvia Nelson · Prevention of Future Deaths report View report

29 Apr 2019 Inner West London F. Wilcox

Georgia Sylvia Nelson, who had treatment-resistant schizophrenia and severe persistent symptoms, stepped in front of a train at Gloucester Road Underground Station on 11 May 2018 and was killed instantly. The report raised concerns about the lack of suitable long-term and rehabilitation housing for young people with severe mental illness, inadequate discharge planning, and missed opportunities to improve treatment and consider rehabilitation before discharge.

Joshua Knox-Hooke · Prevention of Future Deaths report View report

1 Aug 2016 London Greater (East) N. Persaud

Joshua Knox-Hooke, a 22-year-old man with psychosis and recent drug use, attended North Middlesex Hospital on 1 December 2014 after cutting his neck and wrist and saying he wanted to kill himself. He left before psychiatric assessment and was later found deceased, partly immersed in Danbury reservoir; the inquest concluded that he died from drowning. Concerns included failure to keep him within eyesight in accordance with hospital policy and wider issues around patients leaving before psychiatric assessment and the handling of the incident.

Sarah McGarrigle · Prevention of Future Deaths report View report

19 Nov 2021 Manchester North C. McKenna

Sarah McGarrigle, aged 23, was found deceased at home on 1 March 2020. She died from catastrophic internal haemorrhage caused by spontaneous rupture of oesophageal varices associated with chronic alcohol use, in the context of trauma, mental disorder and self-neglect. The principal concerns were that relevant information about her history and community behaviours was not properly considered on Aspen Ward, and that a requested assessment of her mental disorder and capacity did not take place.

Jamie Raymond Barlow · Prevention of Future Deaths report View report

7 Apr 2014 Suffolk P. Dean

Jamie Raymond Barlow had been receiving mental health support after concerns were raised about his wellbeing, but communication and coordination between services affected plans for a further assessment. He subsequently failed to attend a GP appointment and was found hanging near his home; concerns included better inter-agency working, clarity about police assistance, and processes for jointly managing mental health assessments where risks were perceived.

Kirsty Clare TAYLOR · Prevention of Future Deaths report View report

28 Jul 2023 Hampshire, Portsmouth and Southampton C. Wilkinson

Kirsty Clare TAYLOR, aged 33, was found dead in the garage at her family home on 25 June 2022 after taking her own life by hanging in the early hours. The report identified concerns about fragmented mental and physical health services, insufficiently developed personality disorder provision, inadequate communication with and listening to families, and insufficient information and support for families of patients with neurodiversity.

Mark Stuart VIDLER · Prevention of Future Deaths report View report

11 Jan 2026 Kent and Medway I. Potter

Mark Vidler had severe depression and was receiving mental health care from Kent and Medway Mental Health NHS Trust. After serious suicide attempts on 30 April and 7 May 2025, he was discharged from the Home Treatment Team and was not reviewed by an out-of-hours clinician on the night of 7 May after a Rapid Response Team referral was declined. He was found dead at home on 8 May 2025, and the inquest concluded that his suicide was contributed to by a failure in care. Concerns included shortcomings in patient-centred care, clinical oversight and referral processes, risk recognition, discharge decision-making, continuity of care, care coordination, and the implementation and recording of suicidality management.