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Natasha Raghoo · Prevention of Future Deaths report View report

6 Mar 2014 West Sussex D. Skipp

Natasha Raghoo was admitted to The Dene Hospital in April 2012 for treatment related to bipolar disorder and was later detained under section 2 of the Mental Health Act. She was found unresponsive in bed on 5 May 2012 and died from anaphylactic shock caused by an unknown allergen. Concerns included inconsistent physical observations, lack of ECG assessment, staff training in resuscitation and defibrillator use, and communication and handover problems.

Mylon Sheppard · Prevention of Future Deaths report View report

17 Jan 2019 Warwickshire S. McGovern

Mylon Sheppard hanged himself at home and was found on 3 October 2018. The report identified concerns about oversight of duty workers' decisions, waiting-list management, non-attendance processes, family involvement in care planning, and the identification of GP and geographical boundaries for local mental health services.

Callum Oliver SMITH · Prevention of Future Deaths report View report

7 Jun 2017 Avon M. Voisin

Callum Oliver SMITH was in the care of HMP Bristol when he was found hanging in his cell and died from hanging. The inquest concluded that his death was caused by suicide while he was suffering extreme anxiety and distress. Concerns included inadequate risk assessment and mental health assessment, poor communication and record-sharing, and repeated failures to open an ACCT due to training and staff-understanding issues.

Janet BLACKMAN · Prevention of Future Deaths report View report

29 Apr 2014 West Sussex M. Burgess

Janet Blackman became unwell and was treated for hyperthyroidism and low sodium before being transferred between a medical unit and a psychiatric unit. She died after developing a pulmonary embolus due to deep calf venous thrombosis; the report noted that the psychiatric unit could not administer the prescribed heparin prophylaxis and raised concerns about continuity of physical healthcare and application of DVT prevention policy in psychiatric settings.

Lee Francis Grimes · Prevention of Future Deaths report View report

26 Jul 2016 Manchester West R. Griffin

Lee Francis Grimes, who was known to misuse cocaine and had schizophrenia, was found collapsed and unresponsive at home on 21 March 2016. Before his death, he disclosed on two occasions that he had taken an overdose of prescribed medication, but the disclosures did not result in assessment or treatment, and a message to the Community Mental Health Team was not followed up or acted upon. The report raised concerns about failures in responding to overdose disclosures and referral messages, and about staff training and procedures.

John William THORPE · Prevention of Future Deaths report View report

23 Jul 2014 South Lincolnshire P. Cooper

John William THORPE, aged 78, died by drowning after he was found in the Forty Foot Drain on 24 March 2014. Before his death, he had reported low mood, hopelessness and self-harm, was prescribed fluoxetine, and was asked to self-refer to psychological therapy. The concerns included the lack of a direct mental-health referral, the absence of a definite follow-up arrangement, and whether the risks associated with starting antidepressants and his history of suicidal behaviour were adequately considered.

Piotr Kierzkowski · Prevention of Future Deaths report View report

12 Oct 2020 Suffolk N. Parsley

Piotr Kierzkowski was found deceased at home on 17 December 2019 after experiencing a mental health crisis and being assessed for admission to a psychiatric unit. No bed was available, so he was sent home with a friend and took his own life before he could return to hospital. The principal concerns were overall bed capacity for people seeking informal admission and arrangements for temporarily housing a patient when a bed is unavailable.

Evan Amon DANDOU-DAMBELLE · Prevention of Future Deaths report View report

29 Oct 2025 Inner North London M. Hassell

Evan Dandou-Dambelle was at home on the evening of 2 May 2025 while experiencing symptoms of psychosis and command hallucinations. The concerns relate to a change in his mental-health service contact from weekly to fortnightly at the same time that his olanzapine was stopped and risperidone commenced, without the medication change being specifically considered when setting the level of contact. The inquest determined that he died by suicide.

Karis Florence Braithwaite · Prevention of Future Deaths report View report

20 Sep 2019 East London N. Persaud

Karis Florence Braithwaite, aged 24, died after stepping in front of a fast train on 24 September 2018 following discharge from a Section 136 mental health assessment. The concerns included important risk information from the paramedic and police not being available to the assessment team, and handover information not being adequately documented or transferred into the Trust’s records.

Terence Joseph Pimm · Prevention of Future Deaths report View report

14 Aug 2017 Essex C. Beasley-Murray

Terence Joseph Pimm died after leaping from the seventh floor of a car park on 26 August 2016, following recent threats to jump and contact with police, hospital and probation services. The substantive concerns included call handling and record-keeping, guidance and training, assessment of immediate risk, involvement of family members in mental health assessments, information sharing and coordination, and clinicians’ understanding of warrants.

Sunny Elise EYMOND · Prevention of Future Deaths report View report

6 May 2026 Hampshire, Portsmouth and Southampton S. Burge

Sunny Elise EYMOND died at Winchester Hospice on 27 May 2024 after a long history of anorexia nervosa, personality disorder and complex post-traumatic stress disorder, including hospital admissions and periods of forced feeding. The report identified communication and oversight failings during her transfer of care between Hampshire and Bristol services, including the absence of a robust care package, planned 1:1 professional support and a suitable risk management plan. Concerns were raised about the lack of national guidance and treatment pathways for cross-Trust transfers involving people with eating disorders and complex emotional needs.

Tobias Ryse Mannering-Jones · Prevention of Future Deaths report View report

14 Mar 2024 Manchester South A. Mutch

Tobias Mannering-Jones became homeless, isolated and vulnerable, experienced mental health difficulties, drug use and sexual exploitation, and was found dead at Portland Basin Marina on 21 February 2023. The inquest identified concerns about delays in mental health support, inadequate housing and sustained support for vulnerable homeless young people, difficulties contacting people without telephones or addresses, failure to recognise exploitation, and the need for coordinated agency responsibility.

Susan Janet ADAMS · Prevention of Future Deaths report View report

21 Apr 2021 Staffordshire South A. Haigh

Susan Adams was found dead in a hotel in Sutton Coldfield on 4 November 2020 after being unable to live at her home in Tamworth. Her death resulted from the consequences of excessive alcohol consumption, with the inquest recording combined toxicity of ethanol, pregabalin and fentanyl with hepatic cirrhosis and steatosis. The report raised concerns about commissioning difficulties affecting access to regular secondary psychiatric care because her home address and GP practice were in different counties.

Mahamoud Hussain Ali · Prevention of Future Deaths report View report

10 Jul 2024 Inner North London S. Naqshbandi

Mahamoud Hussain Ali fell twice in the street on 19 August 2020 and was later detained under the Mental Health Act and transferred to Lea Ward. On 21 August 2020 he was found unresponsive and died in hospital on 26 August 2020. The principal concern was that required 15-minute observations were not conducted or were falsely recorded, and that subsequent Trust action had not been sufficient to ensure observations were conducted and recorded as required.

Mr Tommy Faegh Faisali · Prevention of Future Deaths report View report

6 Jul 2015 Inner West London F. Wilcox

Mr Tommy Faegh Faisali, who had hepatitis C causing cirrhosis and was methadone dependent, was found deceased in his accommodation on 30 September 2014. The inquest concluded that the medical causes of death included acute pulmonary oedema, methadone toxicity and liver failure due to cirrhosis, with the jury recording drug-related misadventure. Concerns included the lack of specialist psychiatric assessment despite GP referrals, inadequate risk assessment and documentation, and poor communication and continuity of care within mental health teams.

Aminata Coulibaly · Prevention of Future Deaths report View report

26 Nov 2025 Essex S. Hayes

Aminata Coulibaly died at home between the evening of 24 June and the morning of 25 June 2022 from acute alcohol toxicity, with respiratory depression as the mechanism; the manner in which the alcohol entered her system could not be determined. The report identifies concerns about safeguarding, information-sharing and recording by Essex Police and the mental health trust, including failures relating to her expressed suicidal thoughts and the handling of the hate crime investigation.

Daniel Robert Nelson · Prevention of Future Deaths report View report

12 Sep 2022 Lancashire and Blackburn with Darwen N. Rheinberg

Daniel Robert Nelson had a history of schizophrenia, drug dependency, homelessness and imprisonment. After discharge from mental health care with inadequate planning and without required section 117 support, he was placed in unsuitable emergency accommodation with access to drugs and died from an accidental heroin overdose; concerns included the absence of Trust protocols, policies or adequate procedures for section 117 discharges.

Dennis Bennett · Prevention of Future Deaths report View report

12 Apr 2016 Manchester South J. Kearsley

Dennis Bennett had dementia and was admitted under the Mental Health Act before receiving end-stage palliative care on a mental health ward, where he died of natural causes on 7 February 2016. Concerns included an urgent deprivation of liberty application made while he was already detained under Section 3, uncertainty about the application’s continuation, confusion about place-specific authorisations, and limited consideration of whether the application was needed while he was compliant and receiving palliative care.

George Kenneth Fraser · Prevention of Future Deaths report View report

23 May 2025 East London N. Persaud

George Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.

Peter Daniel Usher · Prevention of Future Deaths report View report

2 Dec 2016 East London N. Persaud

Peter Daniel Usher, aged 39, was detained under Section 136 after expressing suicidal intentions and being found threatening to harm himself. He was discharged from hospital in the early hours of 28 December 2015 and was likely to have returned to the school grounds the following day, where he died by hanging; his body was found on 21 January 2016. Concerns included the adequacy of the mental health and risk assessment, failures to obtain and share relevant information, staffing and procedural issues, and insufficient oversight of Section 136 clinical decision-making.