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Callum James Hargreaves · Prevention of Future Deaths report View report

28 May 2025 Cornwall and Isles of Scilly A. Cox

Callum James Hargreaves, who had substance misuse issues and was sleeping rough, was removed from a cliff edge on 19 January 2024 and underwent a mental health assessment before being discharged to emergency accommodation. His body was recovered from the sea the following day, and the inquest concluded that he died from suicide due to multiple injuries. Concerns included unrecorded reasons for not detaining him, insufficient exploration of his wish not to inform his mother, incomplete nearest-relative details, and gaps in record keeping.

Natalie Zara HUNTER · Prevention of Future Deaths report View report

18 Dec 2018 Isle of Wight C. Sumeray

Natalie Zara HUNTER, who had a history of mental health and alcohol-related problems and 18 previous serious suicide attempts, was found deceased in her apartment on 16 March 2018 after suspending herself by a ligature. The report raised concerns about delayed or missing discharge summaries from the Isle of Wight NHS Trust, affecting continuity of GP and mental health care, and about insufficient out-of-hours mental health and crisis staffing on the Isle of Wight.

Ursula Niamh MacEochaigh Keogh · Prevention of Future Deaths report View report

21 Nov 2018 West Yorkshire (Western) M. Fleming

On 22 January 2018, 11-year-old Ursula Niamh MacEochaigh Keogh left school, got off the bus early and jumped from North Bridge in Halifax; she was later found in the river and pronounced deceased. The inquest heard concerns about inconsistent advice and communication between health and education professionals regarding referral for assessment of Ursula’s self-harm, as well as preventative measures at North Bridge.

Wendy Siobhan EYLES · Prevention of Future Deaths report View report

22 Dec 2025 Northamptonshire H. Shah

Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric treatment.

John Ashley · Prevention of Future Deaths report View report

16 Mar 2020 West Sussex P. Schofield

John Ashley took his own life while suffering a deterioration in his mental illness, according to the inquest conclusion. The report identified concerns about failures to update his care and treatment plan, record and share key information, review his deterioration and medication non-compliance, and provide adequate clinical oversight and cover arrangements.

Sarah Elizabeth ADAMS · Prevention of Future Deaths report View report

21 Mar 2024 Berkshire A. McCormick

Sarah Adams was found deceased at home on 19 May 2022 after taking a self-administered overdose of prescribed medication with the intention of ending her life. The report identified care and service delivery issues around her discharge from a voluntary inpatient mental health admission, including a misunderstanding about Crisis Team contact and the provision of five days of medication. It also raised concerns about delays in care planning, the response to her deterioration, and staff training in discharge processes, particularly for out-of-area admissions.

RYAN JAMES VOUT · Prevention of Future Deaths report View report

6 Nov 2017 Nottinghamshire A. McNamara

Ryan James Vout, who had paranoid schizophrenia and was apparently unmedicated, stabbed himself in the chest during an attempt by police officers to execute a section 135 warrant on 10 August 2016. He died despite emergency first aid and hospital treatment. The principal concerns were inadequate coordination before his discharge from psychiatric care, the inability to pre-arrange an ambulance for section 135 warrant attendances, and the lack of a formal briefing or risk assessment before officers entered the premises.

Katie MADDEN · Prevention of Future Deaths report View report

30 May 2024 Suffolk N. Parsley

Katie Madden was declared deceased on 4 June 2023 after being found hanging, following a history of mental health conditions, domestic violence, and a toxic relationship. The report identified concerns about the lack of systems to assess and support her vulnerability during child-care proceedings and safeguarding processes, the absence of independent Social Services support, and difficulties obtaining funding for recommended psychological treatment.

Michael Paul Wheeler · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

Michael Paul Wheeler died after jumping from a fourth-floor window at his brother’s home on 26 July 2018, following increasing paranoia and bizarre behaviour. The principal concerns were that he was not reviewed by a psychiatrist, had no treatment plan, and had no planned review on 26 July; broader concerns were raised about pressures on mental health services, including the availability of urgent psychiatric reviews and inpatient beds.

Jonathan Alan Thorpe · Prevention of Future Deaths report View report

7 Jan 2014 Manchester South J. Pollard

Jonathan Alan Thorpe took his own life by hanging from a tree branch in a local cemetery while using illicit drugs and experiencing deteriorating family issues. The report raises concerns that, despite his known history of self-harm and previous involvement with mental health services, his GP consultations did not refer to or seek input from Mental Health Services.

SAMANTHA JANE GOULD (Sam) · Prevention of Future Deaths report View report

28 May 2021 Cambridgeshire and Peterborough N. QC

Sam took a very large quantity of prescribed medication at home in the early hours of 2 September 2018 and died within at most a couple of hours. The local pharmacy had not been told about a safety plan under which Sam’s parents were responsible for her medication. The report identified a concern that, without national action to ensure pharmacies are involved in medication safety plans for mental health patients aged 16–17, similar fatalities could occur.

Bryan Andrews and Mary Andrews · Prevention of Future Deaths report View report

4 Oct 2024 South Yorkshire (Western) T. Rawden

Bryan and Mary Andrews died at their home on 27 November 2022 from multiple stab wounds inflicted by their adult son. The principal concern was a lack of communication between services about the relationship between his epilepsy and psychotic symptoms, resulting in treatment delays, rejected referrals and failures to share important information.

Anthony John William Watson · Prevention of Future Deaths report View report

12 Feb 2019 Birmingham and Solihull J. Bennett

Anthony John William Watson, who had recurrent depression and anxiety and was displaying psychosis and suicidal thoughts, died after cutting his wrists and neck and jumping from a first-floor window on 21 October 2018. He sustained an unsurvivable head injury and died in hospital the following day. The principal concern was that no inpatient mental health bed was available locally despite the need for immediate admission, while out-of-area beds were considered too distant, particularly for older patients and their families.

Finnulla Catherine MARTIN · Prevention of Future Deaths report View report

29 Apr 2015 Inner North London M. Hassell

Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

Jacqueline Anne Potter · Prevention of Future Deaths report View report

24 Apr 2025 Somerset S. Marsh

Jacqueline Anne Potter, known as Anne, died on 5 December 2022 after taking a car and deliberately driving into the path of an HGV tanker on the A303 during overnight leave from a psychiatric unit. The report raises concerns about families not receiving a codified risk and safety planning document for a patient’s first overnight leave, unrestricted access to self-harm websites through secure unit Wi-Fi, and inadequate recognition and provision of menopausal care and training.

Caroline Adeyelu · Prevention of Future Deaths report View report

5 Mar 2026 East London N. Persaud

Caroline Adeyelu died after suffering a fatal stab wound to her chest at home on 30 October 2022, inflicted by her son, who was under the care of community mental health services. The inquest identified inadequate risk assessment and management, insufficient safeguarding and family engagement, poor care coordination and information sharing, and ineffective communication between mental health services and the police.

Siân Louise WITHERIDGE · Prevention of Future Deaths report View report

23 Oct 2017 Inner North London M. Hassell

Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.

Mary WANYA · Prevention of Future Deaths report View report

30 Apr 2014 West Yorkshire (East) D. Hinchliff

Mary Wanya died after falling through a hospital window on 1 November 2011 while in an acutely confused and agitated state. The window restrictor was defective, allowing the window to be fully opened. Concerns included delays in psychiatric assessment, the assessment and treatment of mental illness on the Medical Admissions Unit, her earlier diagnosis and discharge, and the inadequacy of the Trust’s investigation report.

Jamie Neil Elliott · Prevention of Future Deaths report View report

25 Apr 2017 Inner North London E. Buckett

Jamie Neil Elliott died by hanging at his home on 18 November 2016, with an inquest conclusion of suicide. Before his death, he had expressed clear, detailed and escalating suicidal ideation and had declined offered voluntary inpatient admission. Concerns included failures to contact his private therapist and to provide a face-to-face psychiatric assessment after his condition deteriorated.

Simon Anthony Graham · Prevention of Future Deaths report View report

3 Oct 2018 Birmingham and Solihull E. Brown

Simon Anthony Graham, who had recently attempted suicide by overdose, died by suspension from a ligature at a respite centre on 4 May 2018. The report raised concerns about lone working, delays caused by incorrectly labelled room keys, unqualified support workers undertaking suicide risk assessments, and incomplete suicide prevention training.