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William Abel · Prevention of Future Deaths report View report

20 Oct 2015 Leicester City and South Leicestershire L. Brown

William Abel, who had paranoid schizophrenia and was receiving mental health treatment, died after stepping in front of a train on 9 February 2015. The report raised concerns that he was not given a mental health assessment after being removed from the railway lines the previous night, and that inadequate communication with his family left them unaware of professional concerns about a relapse and the expectation that they would keep him safe.

Danny Jay Anderson · Prevention of Future Deaths report View report

25 Jul 2024 East London N. Persaud

Danny Jay Anderson, who had chronic mental health difficulties and was discharged from hospital to inadequate accommodation without a comprehensive risk assessment or safety plan, was found hanging in his room on 30 March 2023 and pronounced dead at the scene. The report identifies concerns about inadequate risk formulation, over-reliance on Danny’s responses about suicidal ideation, insufficient consideration of his history and circumstances, and the absence of a safety plan before discharge from hospital or community mental health services.

Geraldine Liege Kilborn · Prevention of Future Deaths report View report

10 Nov 2014 County Durham and Darlington A. Tweddle

Geraldine Liege Kilborn died in HMP Low Newton after repeatedly self-harming over the 22 days following her reception into the prison; the Jury could not determine her intention when she hung herself. The principal concerns were inadequate sharing and weighting of mental-health information during ACCT reviews, limited review of ACCT records by some panel members, and questions about review-panel membership and her location at the time of death.

Wendy Louise Telfer · Prevention of Future Deaths report View report

14 Feb 2017 Exeter and Greater Devon L. Brown

Wendy Louise Telfer died on 20 March 2016 in hospital from an overdose of purchased non-prescribed medication taken five days earlier; the medical cause of death was recorded as liver failure due to paracetamol overdose, with asthma also recorded. The report identified concerns about missed opportunities to keep Wendy safe, confusion about applying the Mental Health Act in a physical care setting, and the lack of an available psychiatric inpatient bed.

Daniel France · Prevention of Future Deaths report View report

16 Feb 2022 Cambridgeshire and Peterborough P. Barlow

Daniel France was a 17-year-old vulnerable teenager living in a YMCA hostel who died by asphyxiation by hanging; the inquest concluded that his death was suicide. The principal concern was that vulnerable young people known to local authorities and mental health services may not receive adequate support while awaiting substantive treatment, particularly where they are assessed as not requiring urgent intervention but face lengthy waits for psychological therapy.

Joseph William Cooper · Prevention of Future Deaths report View report

30 Apr 2026 Manchester South C. Morris

Joseph William Cooper died outside his home on 19 June 2025 after sustaining multiple traumatic injuries in a fall while profoundly intoxicated. His death was contributed to by depression and alcohol dependence syndrome. Concerns included unmet mental health needs for people with co-occurring mental health and substance misuse conditions, the ready online availability of large quantities of alcohol, and professionals’ lack of access to his mental health records.

Barbara Mary Anne Mayer · Prevention of Future Deaths report View report

23 Mar 2015 Norfolk J. Lake

Barbara Mary Anne Mayer had a history of depression and was found drowned in a nearby pond on 16 November 2014 after leaving her house during the early hours. Concerns included carer fatigue not being followed up, lack of continuity in her care, treatments not being adequately discussed with her, and no urgent mental health assessment being available when she needed help on 14 November 2014.

Kyle Ashley Smith · Prevention of Future Deaths report View report

21 Jan 2014 Manchester West J. Leeming

Kyle Ashley Smith was found unresponsive by his wife on 19 October 2013 and was pronounced dead by ambulance staff. A post-mortem found that his death was due to the combined toxic effects of Tramadol, Codeine and Zopiclone; concerns included a delay in an urgent mental-health referral reaching the assessment team, the reason for which had not been investigated and was not known.

Zarah RAVN · Prevention of Future Deaths report View report

8 May 2024 Surrey K. Hayes

Zarah Ravn, aged 49, was found deceased at home on 3 September 2023 from mixed drug toxicity after consuming unprescribed oramorph and oxycodone alongside prescribed quetiapine. The substantive concerns included failures to carry out regular mental health, physical and medication reviews, inadequate monitoring of those reviews, and a lack of follow-up after HRT was prescribed following a reported deterioration in her mental health.

Mr Peter Lawrence (PL) · Prevention of Future Deaths report View report

1 Jul 2019 Black Country Z. Siddique

Mr Peter Lawrence, a 48-year-old man with paranoid schizophrenia and a history of disengagement from mental health services, was found outside his flat on 8 February 2019 after falling from the balcony and died from traumatic injuries. Concerns included the lack of a joint multi-disciplinary/agency care plan, inconsistent care coordination, and the absence of a coordinated mental health assessment and possible admission when concerns about self-care and disengagement arose.

Megan Davison · Prevention of Future Deaths report View report

15 Jul 2024 Hertfordshire A. McCormick

Megan Davison was found deceased at home on 4 August 2017 after hanging herself with the intention of ending her life. The report identified concerns about her discharge from mental health care, limited integration between physical and mental healthcare, the absence of recognised diagnosis and care pathways for Type 1 Diabetes with Disordered Eating and Diabetic Ketoacidosis, and incomplete information-sharing between healthcare providers.

Roger Gary Leadbeater · Prevention of Future Deaths report View report

23 Jan 2026 South Yorkshire (Western) T. Rawden

Roger Gary Leadbeater died on 9 August 2023 from multiple stab wounds inflicted by a patient detained under the Mental Health Act who had absconded from escorted leave. The report identified concerns about inadequate and poorly recorded handovers between police forces and the mental health trust, which meant significant risk information was not clearly communicated and may have affected decisions to grant leave. It also noted that, as of January 2026, relevant policies and auditing arrangements had not been updated to support the use of new handover forms.

Eve Cullen · Prevention of Future Deaths report View report

8 Jan 2015 Worcestershire G. Williams

Eve Cullen, who had epileptic seizures and a fluctuating peri-ictal confusional state, went missing from her family home on 17 July 2014 and was later found dead in an alleyway on 9 August 2014. The concerns were that a hospital referral was not actioned, two urgent referrals were not treated as urgent, and there was no uniform definition or timeframe for urgent referrals.

David Squire · Prevention of Future Deaths report View report

25 Jan 2018 Black Country E. Serrano

David Squire, a detained patient at The Priory Lakeside View Care Home, took his own life by hanging in Fibbersley Nature Reserve on 25 July 2018 after leaving escorted off-ground leave for a cigarette and not returning. Concerns were raised that smoke-free hospital guidance required smoking patients who refused nicotine replacement to begin leave off grounds, without the staged observation process used for non-smoking patients, and that the guidance did not adequately account for risks in mental health hospitals.

Angela Marie FROST · Prevention of Future Deaths report View report

28 May 2021 Manchester North C. McKenna

Angela Marie FROST was admitted to hospital after a mixed overdose and later went missing with the intention of starving herself to death. She was found at home on 24 August 2020 after taking an intentional overdose of her partner’s old medication; the inquest recorded the medical cause of death as amitriptyline overdose and concluded suicide whilst the balance of her mind was disturbed. The principal concerns included the absence of formal processes for seeking second opinions and inadequate understanding of confidentiality and permissible communication with family members.

Odessa Carey · Prevention of Future Deaths report View report

12 May 2023 North Northumberland and South Northumberland A. Hetherington

Odessa Carey was last seen alive at her home on 4 April 2019 and was found dead on 7 April 2019; the inquest recorded the conclusion “Unlawfully killed”. The report raised concerns about multi-agency risk assessment, substance-misuse referrals, discharge and care coordination, risk assessment, record keeping, and delays in referral to the Community Treatment Team.

Hedley Frederick ROBINSON · Prevention of Future Deaths report View report

14 Dec 2021 Milton Keynes T. Osborne

Hedley Frederick ROBINSON died on 14 April 2019 after sustaining multiple stab wounds inflicted in Newport Pagnell on 24 March 2019. The concern identified was that a Mental Health Act section 136 assessment was conducted without full information or discussion with relevant senior police officers and others involved in the assailant’s care, prompting concern about the operation of section 136 procedures in Milton Keynes.

Mr Warren James Green · Prevention of Future Deaths report View report

12 Jan 2025 Essex J. Mellani

Mr Warren James Green, who was receiving care in an acute hospital following a serious attempt on his life, died on 20 August 2024 after jumping through a gap in a four-storey stairwell and sustaining a skull fracture and traumatic subdural haemorrhage. The concerns identified included delays in securing a psychiatric bed, inadequate supervision and safeguarding for a patient at high risk of self-harm, patients being able to leave the acute ward without appropriate assessment or staff awareness, and unclear escalation to consultant psychiatric oversight.

Adam James Carter · Prevention of Future Deaths report View report

12 Jul 2018 Blackpool and the Fylde A. Wilson

Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.

Caroline Diane Harris · Prevention of Future Deaths report View report

2 Jul 2024 Oxfordshire N. Graham

Caroline Diane Harris, who had a long-standing diagnosis of severe mental illness, was found deceased at home on 26 July 2023, and a medical cause of death could not be ascertained because of decomposition. Information about her declining mental health, refusal of medication and concerns raised by police was not shared with the Adult Mental Health Team, which limited its ability to supervise and follow her up. The principal concern was that important information was not shared between agencies and that appropriate interventions may consequently not have been made.