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Azra Parveen HUSSAIN · Prevention of Future Deaths report View report

25 Mar 2021 Birmingham and Solihull E. Brown

Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

Steven Paul David Gary Stout · Prevention of Future Deaths report View report

3 Mar 2021 East London G. Irvine

Steven Paul David Gary Stout was detained under section 136 of the Mental Health Act after cutting both wrists while intoxicated by alcohol, and was later admitted to a mental health ward. He was discharged on 18 October 2019 without a referral to the home treatment team and was found unresponsive, suspended by his neck from a ligature, on 4 November 2019; he could not be resuscitated. The concerns included failures to accurately record and file important medical records and to ensure an effective referral to the home treatment team.

Matthew Paul Braben · Prevention of Future Deaths report View report

1 Aug 2024 West London A. van Dellen

Matthew Paul Braben died by asphyxia at HMP Wormwood Scrubs on 16 August 2021 after being found in his cell with his neck, wrists and ankles tied. The report identified concerns including failures to identify and respond to suicide risk, inadequate communication and record-keeping, failures relating to ACCT processes, and the impact of prisoners being held in their cells for up to 23 hours a day.

Jake Robinson · Prevention of Future Deaths report View report

9 Dec 2015 Manchester South J. Kearsley

Jake Robinson died at home on 23 August 2015 after taking his own life; the recorded cause of death was hanging and illicit drug use. Concerns included failures to share information about prescribing diazepam, the failure to identify this issue in the review of his death, fragmented substance-misuse services, and the unexplained rearrangement of a Community Mental Health Team appointment shortly before his death.

Alan Joseph Whelan · Prevention of Future Deaths report View report

7 May 2026 West Yorkshire Eastern O. Longstaff

Alan Whelan, a serving prisoner at HMP Leeds, was moved to the Segregation Unit after starting a fire in his cell while on an open ACCT document. A required mental health assessment was not carried out within 24 hours, and he was later found hanging in his cell and died in hospital on 30 December 2024. Concerns included non-compliance with the mandatory assessment requirement and failures relating to the frequency of ACCT observations.

William Peter Edge · Prevention of Future Deaths report View report

4 Oct 2018 Birmingham and Solihull E. Brown

William Peter Edge was found hanging in the shed at his home in Birmingham on 18 August 2018, after an ambulance crew attempted resuscitation. He had depression, a history of self-harm, and had attempted to hang himself the previous day before being assessed and discharged with a referral to the home treatment team. Concerns included the home treatment team being unable to return when his wife reported that he was in imminent danger, and wider pressures on inpatient beds and home treatment services, including a stated risk to life when patients cannot be attended as required.

Bruce LONGDEN · Prevention of Future Deaths report View report

21 Apr 2015 Brighton and Hove V. Hamilton-Deeley

Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.

Ella Louise Murray · Prevention of Future Deaths report View report

7 Feb 2025 Mid Kent and Medway C. Wood

Ella Louise Murray was 13 years old when she died at Kings College hospital on 15 November 2023 following an episode of hanging, after a period of self-harm, suicidal ideation and deteriorating mental health. The report raised concerns about the adequacy of her risk assessment and the failure to take urgent protective action, including removing her from home or convening an urgent multi-agency response. It also identified the lack of shared information and records across health, social care and education services.

Molly Ann Sergeant · Prevention of Future Deaths report View report

19 Feb 2023 Essex S. Hayes

Molly Ann Sergeant, aged 17, was found deceased on 16 October 2020 after hanging, having left a note. The report identifies concerns about delayed autism diagnosis, insufficient assessment and discharge planning, failures in social-care assessments and coordination, and a lack of understanding of her aftercare rights and chronic suicide risk.

Morgan Rose Betchley · Prevention of Future Deaths report View report

2 Jan 2025 West Sussex, Brighton and Hove L. Milner

Morgan Rose Betchley had a history of mental health difficulties, self-harm and attempts to take her life, and was receiving inpatient care before she died after hanging herself in hospital grounds while awaiting a discharge meeting. The report identified a lack of policy or guidance for assessing risks posed by hospital fixtures and fittings. The inquest also described failures concerning admission, diagnosis, risk management, record keeping, family involvement, discharge planning, staff conduct and the quality of observations and interactions.

Rachel Louise MORTIMER · Prevention of Future Deaths report View report

20 Jan 2024 South Yorkshire (Western) M. Whittle

Rachel Louise Mortimer took her own life on 25 June 2023 by hanging, following previous overdoses and a recent episode involving overdose and an attempt to hang herself. The report identified concerns that family and paramedics were not given advice about available support or emergency options, and that no alternative service was arranged after a planned risk-mitigation referral was unavailable.

Jade Hutchings · Prevention of Future Deaths report View report

28 Oct 2022 West Sussex P. Schofield

Jade Hutchings, who was 18, had been struggling with his mental health and using alcohol and drugs. After going missing while under their influence, he was found hanging at home and died in hospital on 23 May 2020. Concerns included inadequate police mental-health training and a lack of early-intervention provision for older children through the REBOOT scheme.

Matthew Clive GALE · Prevention of Future Deaths report View report

13 Aug 2024 County Durham and Darlington S. Connolly

Matthew Clive Gale died on 19 March 2023 after being detained under the Mental Health Act and granted Section 17 leave. The conditions of his leave, including that he should not be left alone, were not properly recorded or communicated to his family. The report raised concern about inconsistent compliance with providing Section 17 leave forms and the removal of a requirement for the accompanying person to sign the form, creating a risk of future deaths.

Axel Price · Prevention of Future Deaths report View report

15 Apr 2024 West Sussex, Brighton and Hove P. Schofield

Axel Price, who had recently turned 18, died by a ligature at some time between 15 and 23 April 2021 after discharge from hospital and Police custody into temporary accommodation. The report identified concerns about unclear agency responsibility and inadequate support during his transition from child and adolescent mental health services to adult services, including failures relating to discharge planning, risk assessment, capacity assessment and ongoing engagement.

David Joyce · Prevention of Future Deaths report View report

25 Jun 2026 Devon, Plymouth and Torbay A. Longhorn

David Joyce, who had a history of mental health difficulties, died by suicide at his home on 31 August 2023 after being found having suspended himself. The concerns included a lack of follow-up and consideration of mental health referral after he first sought help, prescribing Quetiapine without specialist input despite his reported symptoms and overdose, and a delay of 15 weeks before a medication review led to a change in treatment.

John David Moore · Prevention of Future Deaths report View report

8 Feb 2022 Essex S. Horstead

John David Moore had a history of homelessness, mental health issues, substance misuse and previous suicide or serious self-harm incidents. He died by suicide on 10 June 2021 while homeless, after no recorded intervention from primary or secondary care since 2020. The report identified concerns about inadequate training and supervision of EPUT Care Coordinators, including shortcomings in record keeping, care planning, communication, recognition of disengagement and escalation of concerns.

Janette Insley · Prevention of Future Deaths report View report

16 Dec 2014 Manchester North L. Hashmi

Janette Insley had a longstanding history of depressive illness and was admitted to a mental health unit after her mental and psychological health deteriorated. After failing to return from home leave on 3 August 2014, she was found deceased at home having self-ligatured; concerns included a lack of inpatient psychological therapy provision and delays in accessing community-based therapy after discharge.

Joshua Adey Rennard · Prevention of Future Deaths report View report

7 Mar 2022 South Yorkshire (Western) S. Eccleston

Joshua Adey Rennard died by hanging at his parents’ home on 29 September 2021. The principal concern was an eight-day delay in actioning a professional view that he should be assessed for detention under section 2 of the Mental Health Act, with concern that similar delays could place people at risk of harm or death.

Kiefer Kiam Bolangi Fraser-Phillips · Prevention of Future Deaths report View report

15 Apr 2026 Birmingham and Solihull L. Hunt

Kiefer Kiam Bolangi Fraser-Phillips, who had treatment-resistant paranoid schizophrenia and several physical health conditions including sleep apnoea, was found deceased in bed at a mental health unit on 18 September 2025. The post-mortem medical cause of death was recorded as sudden unexplained death in schizophrenia. Concerns included incomplete recording of therapeutic observations because of Wi-Fi problems and the absence of a care plan addressing physical health risks associated with his medication and sleep apnoea.

Julia Jane MacPherson · Prevention of Future Deaths report View report

1 Apr 2018 South London S. Hayes

Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.