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Dean Mark Rowland · Prevention of Future Deaths report View report

27 Jun 2017 Staffordshire South M. Jones

Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report View report

27 Jun 2014 Manchester City N. Meadows

Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.

Jayden Andrew Booroff · Prevention of Future Deaths report View report

27 Jan 2023 Essex S. Hayes

Jayden Andrew Booroff died after absconding from The Linden Centre and being struck by a train on 23 October 2020. The report identified concerns about risk assessments, observation levels, ward security, absconsion procedures, record keeping, medication, and communication between healthcare professionals and emergency services.

Christopher John Bird (“Chris”) · Prevention of Future Deaths report View report

23 Sep 2025 Wiltshire and Swindon D. Ridley

Christopher John Bird died by suicide on 19 September 2024 after placing his head on a railway line near South Marston and being struck by a freight train. The report found that a mental-health response sent to primary care was not received, and that this communication failure meant he was not updated about his referral and more likely than not exacerbated his mixed anxiety and depression. It also raised concern about the reliability of nhs.net email for transmitting important information between mental-health and primary-care services.

Katherine Liana Bonaventura · Prevention of Future Deaths report View report

28 Jan 2015 Surrey A. Hewitt

Katherine Liana Bonaventura, a patient detained under the Mental Health Act, returned to the Abraham Cowley Unit on 7 December 2012 after overnight leave with a concealed knife and fatally stabbed herself a few hours later. The principal concerns were that relevant information about her leave was not elicited from her family member, her mental state was not assessed sufficiently and immediately on return, and there was no system to ensure thorough consultation and assessment or recording of the assessment outcome.

Donna Neill · Prevention of Future Deaths report View report

28 Sep 2022 East London N. Persaud

Donna Neill was found deceased at home on 10 December 2018 after an overdose involving medication prescribed to her husband. The report identified that the risk of her taking medication not prescribed to her was not fully assessed, documented, or managed, and that no risk management plan was put in place.

MARTIN LEE TILLEY · Prevention of Future Deaths report View report

12 Mar 2018 Gloucestershire C. Saunders

Martin Lee Tilley had a long history of substance misuse and significant mental health problems, including self-harm discussions, suicidal thoughts, and apparent visual and auditory hallucinations before his last appointment with the Homeless Healthcare Team in July 2017. He was found deceased on 17 October 2017 from the combined toxic effects of prescribed and non-prescribed medication; concerns were raised that there was no evidence of follow-up by the team after July and no answer explaining whether his presentation should have led to an emergency psychiatric assessment or referral to tertiary mental health services.

Simon Robinson · Prevention of Future Deaths report View report

7 Mar 2019 Oxfordshire D. Salter

Simon Robinson died at home on 2 February 2018 after stabbing himself in the neck with a kitchen knife during a psychotic episode. His wife’s 999 call requesting police attendance was incorrectly graded, resulting in a delayed response. The principal concern was that the partnership agreement between police and mental health services did not adequately cover mental health crises in private places, including the expected initial police response when there is a fear for welfare or safety.

Cynthia Elizabeth Finlay · Prevention of Future Deaths report View report

11 May 2022 Surrey C. Topping

Cynthia Elizabeth Finlay had depression, cognitive difficulties and impulsive personality traits. After an overdose and discharge from hospital, she was assessed by mental health professionals, but no adequate safeguarding plan was put in place while she was awaiting consideration of a Mental Health Act assessment. She was left alone and subsequently died by suicide; expert evidence identified that no protocol governed safeguarding people in this situation who might be alone and at risk in the community.

Sheila Graham · Prevention of Future Deaths report View report

16 Nov 2018 Stoke-on-Trent and North Staffordshire M. Jones

Sheila Graham was admitted to hospital after a fall causing a complicated ankle fracture, subsequently developed infection and clostridium difficile, and died on 13 October 2017 after an upper gastrointestinal bleed. Concerns included the effects of prolonged isolation on her mental and general wellbeing, inadequate recording and monitoring of nutrition despite weight loss, and delayed referral to mental health and dietetic services.

Abigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after unsuccessfully trying to suspend herself, and was pronounced dead at 00:08 on 16 February 2022 from compression of the neck. The report describes concerns about failures in mental-health care, including inaccurate records and diagnosis information, inadequate adjustments for autism and learning difficulties, medication-management problems, and discharge from detention without an effective plan to mitigate a known and immediate risk of suicide.

Marcus HANCE · Prevention of Future Deaths report View report

7 Jun 2018 Cornwall and Isles of Scilly G. Davies

Marcus Hance died on 13 October 2017 from the synergistic effect of a reckless overdose of illicit and therapeutic drugs, in the context of a history of drug abuse. Concerns included the separation of support for substance misuse from support for associated mental health issues, the approach that substance misuse should be addressed before mental health treatment, and his discharge from the Community Mental Health Team after two missed appointments.

Terence Andrew Bennett · Prevention of Future Deaths report View report

14 Sep 2018 Wiltshire and Swindon N. Rheinberg

Terence Andrew Bennett, who had schizo-affective disorder and was severely mentally ill, suicidal and threatening harm to his mother, died by suicide after self-inflicting deep wounds to his neck and wrists on 26 October 2016. The inquest found that his death was contributed to by neglect. Concerns included inadequate care and risk-management plans, failures in record use and handover, insufficient family and multidisciplinary involvement, reliance on unqualified staff, and deficiencies in supervision, training and consultant working arrangements.

Wendy Siobhan EYLES · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated between services.

Tcherno Bari · Prevention of Future Deaths report View report

3 Jun 2024 Birmingham and Solihull J. Bennett

Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.

Sidi Chax Bojang · Prevention of Future Deaths report View report

1 Aug 2025 North London A. Walker

On 19 July 2024, Sidi Chax Bojang left the platform at Oakleigh Park Railway Station and was struck by a fast train. He had recently attended hospital after reporting self-harm and experiencing a “wooshing” sound and flashes of light, and had called an ambulance on the morning of his death after cutting himself. The concerns included that possible serious mental illness and hallucinations were not recognised, that a psychiatrist did not review him before discharge, and that discharge was left to a senior psychiatric nurse.

Keiran Michael John Toman · Prevention of Future Deaths report View report

12 May 2014 Inner West London F. Wilcox

Keiran Michael John Toman had fixed delusions, withdrew from social and psychiatric support, and subsequently starved himself to death due to paranoia before being found deceased in a hotel. The report raised concerns that psychiatric services did not maintain contact with his family despite his lack of insight and capacity, potentially leaving him isolated and increasing the risk of deterioration and death.

David Gary Chatburn · Prevention of Future Deaths report View report

18 Mar 2014 Manchester North L. Hashmi

David Gary Chatburn had a significant history of mental health problems, including depression, probable bipolar disorder, alcohol misuse and fluctuating mood. He was found hanging from a tree on 18 October 2013, and the inquest concluded that he took his own life while the balance of his mind was disturbed. Concerns included the lack of referral to psychiatric services, the GP-led diagnosis and treatment, medication management, informal follow-up, record keeping and barriers in accessing mental health services.

Mr Gregory Rekowski · Prevention of Future Deaths report View report

28 Dec 2018 Manchester North J. Kearsley

Mr Gregory Rekowski was detained under the Mental Health Act after being found trying to tie a ligature, discharged from hospital, and later posted “last goodbyes” on social media. He was found hanging at his home on 29 October 2017. The report identified concerns about delays, communication breakdowns, unclear responsibilities and procedures among Pennine Care NHS Trust, Greater Manchester Police and North West Ambulance Service, including the lack of a face-to-face assessment.

Mr Darren Clifford Docherty · Prevention of Future Deaths report View report

14 Apr 2023 Staffordshire and Stoke on Trent E. Serrano

Mr Darren Clifford Docherty was released from HMP Stoke Heath without accommodation and was subsequently found hanging from a tree on 10 August 2023. The report raised concern that people released from prison without accommodation may be unable to access GP and community mental health services.