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Saima Hussain · Prevention of Future Deaths report View report

15 Apr 2021 Manchester South A. Farrow

Saima Hussain had a history of mental health difficulties and took her own life by hanging in August 2019. The report raised concerns that communication about her referral from the Community Mental Health Team to Psychological Therapies Services was not reliable, direct, or tailored to her needs, leaving her without a clear point of contact or adequate information about her care plan.

Tom Sweeting · Prevention of Future Deaths report View report

19 Jan 2024 West London L. Brown

Tom Sweeting experienced a sudden deterioration in his mental health in August 2021 and was assessed by liaison psychiatry after reporting suicidal thoughts. On 20 August 2021, he was found suspended by a ligature at home after locking himself in the garage, and resuscitation attempts were unsuccessful. Concerns included incomplete clinical assessment documentation, failures in discharge communication and treatment-plan communication, delegation of family collateral information gathering to a junior trainee, and a lack of evidence that new training and procedures had been effectively audited.

Zak Miles Joe Walter Paul Farmer · Prevention of Future Deaths report View report

24 Sep 2020 Essex C. Beasley-Murray

Zak Miles Joe Walter Paul Farmer, a 23-year-old man, died on 21 July 2019 after being found hanging. Concerns included a lack of clarity about the meaning of “urgent” referrals to the Access and Assessment Team and shortcomings in guidance for community mental health service users disengaging from prescribed treatment plans.

John WILLIAMS · Prevention of Future Deaths report View report

28 Mar 2017 Inner North London M. Hassell

John Williams hanged himself while he was a prisoner at HM Prison Pentonville, after telling staff that he would do so if his perceived needs were not met rather than intending to take his life. Concerns included inaccuracies and omissions in reception screening and referrals, inadequate understanding and use of the ACCT document, insufficient training for some support staff, confusion about emergency codes, and a lack of basic first aid and CPR training among prison officers.

Antony Christopher MCLELLAN · Prevention of Future Deaths report View report

5 Jul 2022 North Yorkshire and York J. Broadbridge

Antony Christopher McLellan was found unresponsive, hanging by a ligature in the garage at his home on 9 July 2021; his death was recognised that afternoon and the inquest concluded that he died by suicide. Concerns included that assessment and formulation of risks and safety did not fully explore the impact of his autism, including how he might communicate distress and risk, and that autism-informed support and services required significant improvement and expansion.

Sheridan Tate Pickett · Prevention of Future Deaths report View report

19 Mar 2025 Manchester South J. Gill

On 9 August 2024, Sheridan Tate Pickett sustained fatal injuries after falling from a height out of a window; the inquest concluded that the death was suicide. The concern was that information about an overdose and advice not to recommence ADHD medication was not shared with the private ADHD provider, and that there were no current guidelines governing information sharing between private psychiatry providers and NHS services involved in parallel care.

Benjamin Colin Williamson · Prevention of Future Deaths report View report

12 Dec 2018 Cornwall and Isles of Scilly A. Cox

Benjamin Colin Williamson had a long history of alcohol-related issues and was receiving treatment, with regular GP contact. He died on 4 April 2018, and the inquest recorded a conclusion of suicide, with asphyxia by hanging and alcohol intoxication. Concerns included fragmented mental health services for people with both mental health and alcohol problems, and inadequate liaison and feedback between Addaction and the GP.

Jonathan Daniel Zucker · Prevention of Future Deaths report View report

26 Jun 2017 North London A. Walker

Jonathan Daniel Zucker was found at home on 27 November 2016 after hanging himself with a length of rope from banisters. The principal concern was that no lead clinician or system was in place to oversee and coordinate care provided by the private and NHS mental health services.

Mariana Hungria Bayam Veiga PINTO · Prevention of Future Deaths report View report

14 Mar 2017 Inner North London M. Hassell

Mariana Pinto jumped from the third-floor balcony of her home as a deliberate act, without a proper understanding of what she was doing, after attending the emergency department the previous day. The concerns included whether the crisis team’s limitations and possible symptom worsening had been adequately communicated to her family, and whether the urgent crisis-line call was escalated appropriately.

Rowena Kathryn Golton · Prevention of Future Deaths report View report

11 Nov 2014 Manchester South J. Kearsley

Rowena Kathryn Golton had a history of recurring depression, suicidal thinking and deteriorating mental illness. On 6 April 2014, after being assessed as low risk of suicide and discharged from A&E with a plan for later crisis-team review, she jumped from a fire escape and died from multiple traumatic injuries. Concerns included limited access to psychologists within crisis teams and significant waiting times for psychological therapy.

Laura Hill · Prevention of Future Deaths report View report

20 Feb 2015 Carmarthenshire & Pembrokeshire G. Lewis

Laura Hill, aged 21, was admitted to a psychiatric ward after a serious overdose and later absconded twice before being found hanging from a tree in a wooded area. The concerns identified included information-sharing failures, stretched staffing, training needs around police handovers, absconding, personality disorders and detention powers, and the ward door policy.

JAMES MICHAEL NOWSHADI · Prevention of Future Deaths report View report

29 Jul 2021 Cambridgeshire and Peterborough C. Jones

James Michael Nowshadi died after ingesting a substance he had obtained online to end his life, suffering cardiac arrest and being pronounced dead on 1 April 2020. Concerns included insufficient national guidance and information-sharing about the risks of sodium nitrate/nitrite, missed opportunities for learning from the Serious Incident Review, and a lack of guidance for emergency clinicians on the use of methylene blue in cases involving cardiac arrest.

Mr Alexi Susiluoto · Prevention of Future Deaths report View report

4 Apr 2025 Inner North London R. Brittain

Mr Alexi Susiluoto, who had a history of mental health disorders, substance misuse and epilepsy, was found deceased in a hotel room on 22 May 2024. His death was attributed to alcohol misuse disorder resulting in acute ethanol toxicity, with epilepsy and prescribed medication as contributing factors. The report raised concerns about fragmented care for people with dual diagnoses who are homeless, including confusion over which services and local authority were responsible for care and funding.

Mr Mohammed Hussain · Prevention of Future Deaths report View report

13 Mar 2019 Bedfordshire and Luton E. Whitting

Mr Mohammed Hussain died after setting fire to himself inside a car in Luton on 12 March 2018, following deterioration in his mental health and previous overdoses. Concerns included shortcomings in mental health risk assessments, inadequate application of risk assessment training, and failures to share or highlight important information between staff and care providers.

Nigel Hutton HAMMOND · Prevention of Future Deaths report View report

9 Oct 2024 Suffolk N. Parsley

Nigel Hammond died at Addenbrooke’s Hospital on 14 March 2024, three days after falling from a window at home and sustaining serious injuries. The inquest concluded that the death was suicide while the balance of his mind was disturbed. The principal concern was that the AMHP could not directly refer Nigel to the Crisis Resolution and Home Treatment Team, and that this may have delayed support before his fatal fall.

Edward Angus Mallen · Prevention of Future Deaths report View report

7 Sep 2016 Cambridgeshire and Peterborough B. Cheney

Edward Angus Mallen, who was suffering from depression and had disclosed suicidal thoughts, died after lying across a railway line and being struck by a train on 9 February 2015. The concerns included unclear responsibility for his care, advice from a non-prescriber about medication, lack of information about possible worsening symptoms and increased suicidal feelings, and inadequate awareness of routes to further psychiatric advice.

Peter Stanley · Prevention of Future Deaths report View report

2 Sep 2014 South Yorkshire (Western) P. Dorries

Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

Edward Muwanga · Prevention of Future Deaths report View report

24 Apr 2026 Inner West London P. Rogers

Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

Robert Paul Yarnell · Prevention of Future Deaths report View report

13 Feb 2015 Manchester West R. Griffin

Robert Paul Yarnell died after jumping from Barton Bridge on the M60 Motorway on 8 October 2014, causing multiple injuries. He had been receiving mental health care following a hospital admission, but moving out of the area led to a significant delay in continuing care. Concerns were raised that unclear procedures for transferring care between areas could leave service users without needed support and create risky situations.

Theo Jude BRENNAN-HULME · Prevention of Future Deaths report View report

15 Feb 2022 Norfolk J. Lake

Theo Brennan Hulme, a university student with Asperger’s Syndrome, a history of deliberate self-harm and suicidal thoughts, was found hanging in his room on 12 March 2019 and declared dead at the scene. The report identified concerns about the adequacy and timeliness of his mental health assessment, failure to make reasonable adjustments or involve his family, lack of follow-up after a missed appointment, a persistent culture within the Crisis Resolution Home Treatment Team, and the absence of an immediate review when a person is discharged after assessment.