Search PFD Monitor

Barrie Lewis · Prevention of Future Deaths report View report

19 Feb 2015 Powys, Bridgend and Glamorgan Valleys A. Barkley

Barrie Lewis was found by his family hanging from a rope attached to a garage rafter on 31 August 2014. The inquest concluded that his death was suicide. Concerns included the absence of a specific risk assessment for suicidal ideation, poor communication between mental health services, no reliable system assigning responsibility for assistance, and a lack of clinical records of crisis-team contact.

Stephen James Morris · Prevention of Future Deaths report View report

29 Aug 2014 Blackpool and the Fylde A. Wilson

Stephen James Morris, who had previously been diagnosed with bipolar affective disorder, was found deceased in the bath at his flat on the morning after 16 June 2013. A post-mortem found high levels of mood-stabilising and antidepressant medication, whose combined effects proved fatal; the inquest concluded that he took his own life. The principal concerns were that Mirtazapine was prescribed despite awareness of his diagnosis and its suitability concerns, based on the patient's verbal account rather than confirmation from the mental health team.

Dr Malcolm Dixon · Prevention of Future Deaths report View report

25 Nov 2021 Manchester South C. Morris

Dr Malcolm Dixon became unwell in autumn 2019 with what was later diagnosed as a severe depressive illness and was admitted as an informal, voluntary patient to Priory Hospital, Altrincham. He died there on 29 December 2019 following an impulsive act undertaken in the context of severe mental illness. Concerns included inaccurate observation records, electronic care-record timestamps being overwritten, and the absence of professional documentation requirements for some unregistered staff.

Jennifer Lewis · Prevention of Future Deaths report View report

15 Apr 2019 North West Kent R. Hatch

Jennifer Lewis was admitted to hospital from the Bracton Centre on 21 July 2017 with poor intake, diarrhoea, confusion, dehydration, hypotension and malnutrition, and subsequently deteriorated. The inquest concluded that she died at Darent Valley Hospital on 31 July 2017 as a result of malnutrition due to inadequate provision and intake of sufficient nourishment and nutrition, furthered by an inability to provide the necessary medical intervention at the Bracton Centre. The principal concerns were failures to arrange consultation between mental health and physical health doctors, provide suitable or adequate care for her needs, and provide appropriate care at the Centre.

CLAIRE LILLEY · Prevention of Future Deaths report View report

11 Dec 2020 Inner South London J. Morris

Claire Lilley was detained under the Mental Health Act and admitted to Avery Ward following a significant overdose. While on Section 17 overnight leave at home, she hung herself on 12 February and did not survive. The report identified diffuse risk information, no central risk formulation, and insufficient management cover to review risk as substantive concerns.

John William Sloan · Prevention of Future Deaths report View report

12 Feb 2018 London Inner (South) C. Williams

John William Sloan died by suicide on 16 August 2017 after hanging himself while alone at home. He had been receiving mental health care for anxiety, depression, sleeplessness and suicidal ideation. The principal concerns were that he was not asked about suicidal thoughts or plans at his last face-to-face contact, and that information from his daughter about his distress was not recorded or acted upon.

Andrew James AITKEN · Prevention of Future Deaths report View report

15 Dec 2014 Inner North London M. Hassell

Andrew Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.

James Ralph COCHRANE · Prevention of Future Deaths report View report

5 Sep 2025 Rutland and North Leicestershire R. Connell

James Ralph Cochrane, who had schizoaffective disorder with fluctuating mood and psychosis, died on 17 November 2023 after jumping from an overbridge into the carriageway and being struck by a vehicle. The report raises concerns about how carers’ views and video evidence are considered and used in safety planning, and about the support provided to carers assisting mental health patients at home.

Jeff David ANTWIS · Prevention of Future Deaths report View report

13 Nov 2017 Shropshire, Telford and Wrekin J. Ellery

Jeff David ANTWIS, a 14-year-old teenager with Asperger’s syndrome and a history of self-harm and suicide attempts, was struck by a train at Harlescott level crossing on 30 January 2017 and died later that day. The principal concern was that, despite indicating that he wished to die, he was given a routine medical review appointment for 17 March rather than an urgent review, alongside concerns about risk assessment, referral mechanisms and recognition of how his conditions may have affected the presentation of suicidal ideation.

Joanne Elizabeth Richardson · Prevention of Future Deaths report View report

8 May 2018 Dorset R. Griffith

Joanne Elizabeth Richardson was found suspended by a ligature at her home on 26 September 2017 and the inquest concluded that her death was suicide. Concerns were raised about inadequate communication and lack of joined-up working between mental health teams, which meant important risk information was not shared and could lead to inaccurate risk assessments and a future death.

Alex Alfred ROBINSON · Prevention of Future Deaths report View report

28 May 2026 Shropshire, Telford and Wrekin J. Ellery

Alex Alfred Robinson was admitted to Royal Shrewsbury Hospital on 8 September 2025 and was later found unresponsive at Church Lane, Little Wenlock, Telford, on 10 September 2025 after ligaturing himself; he was declared deceased at the scene. The principal concern was conflicting information about whether the Mental Health Liaison Team was available and whether a formal referral had been made, representing a possible lost opportunity for him to receive appropriate care, although this could not be known to have prevented his death.

Neeshat Dalal · Prevention of Future Deaths report View report

5 Jun 2026 East Sussex R. REDMAN

Neeshat Dalal was admitted for severe depression after experiencing difficulty eating and drinking and undergoing three attempts to end her life with an insulin overdose. She collapsed during her third ECT treatment on 13 December 2022, was transferred to the emergency department, and died in the Acute Medicine Unit in the early hours of 14 December 2022. The concerns included inadequate consideration of her nutritional needs and vomiting, insufficient medical information before ECT, and delays or omissions in aspects of her acute hospital care.

Peter Galea · Prevention of Future Deaths report View report

21 Nov 2013 Sunderland D. Winter

Peter Galea, a 51-year-old man, attended hospital and other agencies repeatedly over a 72-hour period and was assessed as low risk on three occasions. On 11 June, after leaving his GP surgery and threatening to jump from a bridge, his body was found under the Queen Alexandra Bridge and he was pronounced dead. Concerns included limited mechanisms for breaking referral cycles, restrictions on direct GP referral for admission to a place of safety, and whether different action might have prevented the outcome.

Somtera Bibi · Prevention of Future Deaths report View report

2 May 2026 East London N. Persaud

Somtera Bibi, aged 80, died from fatal stab wounds to the chest at her home on 2 April 2022. The report identified concerns about the absence of robust community mental-health risk management, including relapse prevention, family safety planning, DASH risk assessments, safeguarding referrals and multi-agency involvement, despite known risks posed by the family member who inflicted the injuries.

Oladeji Adeyemi Omishore · Prevention of Future Deaths report View report

25 Mar 2025 Inner West London F. Wilcox

Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.

Brian Christopher Dalrymple · Prevention of Future Deaths report View report

18 Sep 2014 West London J. Chipperfield

Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.

Abdullahi Sharif ABOKAR · Prevention of Future Deaths report View report

3 Dec 2013 Inner North London M. Hassell

Abdullahi Sharif Abokar, a 22-year-old patient detained under section 3 of the Mental Health Act, was found hanging from smoke alarm wires on a secure mental health ward on 16 June 2012 and died five days after being taken to hospital. Concerns included staff not asking him about suicidal thoughts and significant shortcomings in the conduct of resuscitation, including compromised ventilatory support and uncertainty about airway management.

Heather FINDLAY · Prevention of Future Deaths report View report

12 Jun 2023 Inner North London M. Hassell

Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

Stephen Thurm · Prevention of Future Deaths report View report

17 May 2021 Manchester South C. Murray

Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.

KAREN JANE BINGHAM · Prevention of Future Deaths report View report

30 Mar 2020 Surrey C. Topping

Karen died by hanging at her home on 18 November 2017 after contacting police and ambulance services. The jury identified concerns about the safeguarding plan used when she was informed that her perjury allegation was being filed, including insufficient information gathering, failure to involve mental health services, and inadequate multi-agency planning. The report also identified concerns about police mental health training and the understanding between police and ambulance services of each other’s triage and dispatch processes.