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Ryan John EVANS · Prevention of Future Deaths report View report

20 Dec 2023 Hampshire, Portsmouth and Southampton D. Stewart

Ryan John EVANS died after being found hanging in the communal area of his accommodation on 3 April 2018. The concerns included that, despite evidence of self-harm and suicidal ideation, no mental health assessment was carried out at hospital, and that mental health information and referrals were not effectively documented or communicated during his time in police custody.

Kimberley Lauren Lindfield · Prevention of Future Deaths report View report

2 Feb 2015 Manchester City N. Meadows

Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

Jack FARRINGTON · Prevention of Future Deaths report View report

14 Sep 2023 Hampshire, Portsmouth and Southampton R. Simpson

Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.

Karl Qolf Jamil Englemak Cassimjee · Prevention of Future Deaths report View report

2 Nov 2018 Manchester West T. Brennand

Karl Qolf Jamil Englemak Cassimjee, who had a history of presumed paranoid schizophrenia and psychosis, was found dead on 5 February 2018 after becoming missing and being last seen behaving irrationally and bizarrely. The medical cause of death was hypothermia, and the inquest concluded accidental death. Concerns included an inadequate Mental Health Act assessment, insufficient risk assessment and safety planning, failures to obtain relevant collateral information, and mental health operational systems identified for revision not having been implemented.

Anthony Hayward BUCKINGHAM · Prevention of Future Deaths report View report

9 Apr 2019 Suffolk D. Sharpstone

Anthony Hayward BUCKINGHAM died at home on 13 March 2018 with a metal cable around his neck, after a previous suicide attempt and ongoing suicidal thoughts. The inquest highlighted concerns about the frequency of mental health visits, involvement of his father and practice nurse, a formal mental health assessment, and use of a care facility.

DAVID WAYNE BENNETT · Prevention of Future Deaths report View report

17 Feb 2025 Essex S. Hayes

David Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.

Jillian Anne Steedman · Prevention of Future Deaths report View report

10 Oct 2025 Essex S. Hayes

Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.

David Jonathon Jukes · Prevention of Future Deaths report View report

12 Jul 2019 Birmingham and Solihull E. Brown

David Jonathon Jukes was declared deceased on 9 October 2018 after being found hanging from a ligature fixed to a garden gate. The report identified concerns about inadequate information sharing, mental-health assessment and follow-up, attempts to locate and engage him, risk assessment, and clinical record keeping, with associated risks to life.

Aaron James DEELEY · Prevention of Future Deaths report View report

19 Jun 2024 Essex S. Hayes

Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.

Miles Ethan Hurley · Prevention of Future Deaths report View report

9 Aug 2024 West Sussex, Brighton and Hove K. Henderson

Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

Carole Mitchell · Prevention of Future Deaths report View report

11 Feb 2021 Manchester South A. Mutch

Carole Mitchell died at home on 22 November 2019 after taking a fatal amount of her prescribed medication; the inquest conclusion was suicide. The report identifies concerns about delays in accessing psychological assessment and support-worker services, limited mental health bed capacity, and difficulties gathering information from her family because of concerns about confidentiality.

Matthew Llewellyn-Jones · Prevention of Future Deaths report View report

25 Oct 2016 Exeter and Greater Devon L. Brown

Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.

John Haines · Prevention of Future Deaths report View report

16 Nov 2017 Manchester North L. Hashmi

John Haines was admitted to a mental health ward in March 2017 after his anxiety and depression deteriorated, and was discharged on 14 June 2017 with planned follow-up. He was found deceased at home on 17 June 2017 after failing to respond to contact. The report raised concerns about in-patients and Home Treatment Team patients being unable to access qualified psychological therapy, including delays in accessing Healthy Minds.

Marcus William George McGuire · Prevention of Future Deaths report View report

23 Jun 2019 Birmingham and Solihull E. Brown

Marcus William George McGuire died at HMP Birmingham on 24 April 2018 after being found in his cell with a ligature around his neck. The inquest concluded that his suicide was possibly contributed to by failures to carry out a mental health assessment, respond to missed anti-psychotic medication, involve mental health services in the ACCT process, assess his risk using all relevant information, and properly manage the ACCT.

Nicola Jane Lacey · Prevention of Future Deaths report View report

26 Jun 2024 Herefordshire H. Gregory

Nicola Jane Lacey lived alone and was found dead at her home after she failed to attend work on 30 December 2022; the inquest concluded that her death was suicide. The report raised concern about the need for clear procedures for employers on disclosing colleagues’ ongoing mental health difficulties, for the benefit of the individual and wider public safety.

Heather Louise Carey · Prevention of Future Deaths report View report

12 Feb 2019 Manchester South A. Bridgman

Heather Louise Carey was admitted to mental health services in July 2017, later took an overdose of paracetamol, and was placed on a 24-week waiting list for Cognitive Analytical Therapy. She hanged herself at home on 20 December 2017. The principal concern was that lengthy waits for psychotherapy and inadequate action to address her high suicide risk may have contributed to her death.

Daniel LYLE · Prevention of Future Deaths report View report

23 May 2023 Inner West London P. Rogers

Daniel LYLE, who suffered from paranoid psychosis, experienced a psychotic episode on 20 March 2020 and climbed approximately 30 feet into a tree while displaying paranoid and delusional beliefs. He fell from the tree, sustained fatal head and chest injuries, and died despite resuscitation efforts. The principal concern was that police training was not sufficiently focused on understanding mental health symptoms and presentation, or on practical strategies to support decision-making during mental health crises.

Noleen Mary McPHARLANE · Prevention of Future Deaths report View report

7 Aug 2014 Inner North London M. Hassell

Noleen Mary McPHARLANE had longstanding contact with mental health services and a history of overdoses and self-inflicted wounds. She died after ingesting an excess of a drug purchased on the internet, although her intentions were unclear. Concerns included that her suicide thoughts and continued illicit amitriptyline use were not directly explored, and that there was no consideration of input from an alternative healthcare professional despite limited therapeutic engagement.

Caroline Ann STAITE · Prevention of Future Deaths report View report

14 Oct 2024 Herefordshire H. Bricknell

Caroline Ann STAITE was recovered from the River Wye near the Canary Bridge, Hereford, after being reported in the river on 8 March 2024, and was pronounced deceased at 0241 hours on 9 March 2024. The concerns related to the robustness of procedures for considering patients for Mind, and to transparent arrangements for returning patients from Mind to the care of the Neighbourhood Mental Health Team.

Martin Gibbons · Prevention of Future Deaths report View report

21 May 2021 Manchester South A. Mutch

Martin Gibbons attempted to take his own life on 19 March 2020 and was taken to hospital, where he was assessed as needing admission to a psychiatric ward. While waiting for a bed, he left the hospital unobserved and was found dead on 24 March 2020; the inquest concluded suicide. Concerns included differing assessments of risk between acute and mental health trusts, the absence of shared risk assessments and care plans, and delays in obtaining a mental health bed.