2,023 reports
Information drawn from published reports and official responses.
Levi Craig Don Pettit was reported to police as having suicidal ideations on 8 December 2019. Four days later, he died by suicide; concerns included the handling of the police response, including the failure to complete or make required referrals and uncertainty about relevant policy and training.
Lincolnshire PoliceRecipient name withheld
Farres Ikken was arrested after stating that he wanted to kill himself, assessed by mental health services, and discharged for follow-up by his GP. Shortly after leaving the hospital, he hanged himself in the hospital grounds; the substantive concern was that hospital staff could not directly refer him to community psychological services on discharge.
Department of Health and Social Care
Sandra Kirk was found unresponsive in the ensuite bathroom of her bedroom at Cygnet Hospital on 2 August 2021 and was declared deceased after resuscitation attempts were unsuccessful. The inquest found that she died from asphyxia due to a ligature around her neck. Concerns included inadequate guidance on identifying and removing potential ligatures, including items of clothing, and the limited risk reduction provided by observation intervals.
NHS England
Marlene McCabe was unlawfully killed in her own home on 4 September 2019 after being struck repeatedly on the head and face with a doorstop, causing catastrophic injuries. The concerns included urgent mental-health referral processes, inconsistent access to and sharing of mental-health records, the risk of substance misuse obscuring mental-health diagnoses, non-communication of material information, and delayed assessment of apparently intoxicated patients.
Blackpool Teaching Hospitals NHS Foundation TrustBloomfield Medical CentreLancashire & South Cumbria NHS Foundation TrustNorth West Ambulance Service NHS Trust
Girmaye Guyo Liban had a long history of mental health illness and substance abuse, was discharged from detention under the Mental Health Act 1983, remained unwell in the community, went missing on 10 November 2020, and his body was found in a reservoir on 26 November 2020. The concern was that the Nearest Relative Power could enable discharge despite a patient continuing to meet the criteria for detention, without a thorough procedure or legal test for clinicians to apply.
Department of Health and Social CareMinistry of Justice
Stephen Ian William Tidey was found deceased on 22 December 2016, having been found hanging from a tree outside the cabin where he was residing, with self-inflicted wounds to both wrists. The report raised concerns that a high-risk MASH referral, made after he lost his job, was not followed up and that there were no safeguards to ensure referrals were acted upon, including outside normal office hours.
Surrey and Borders Partnership NHS Foundation TrustSurrey County CouncilSurrey Police
Michael James Crane lived in supported accommodation and was absent from the Home from 15 January 2024. He attended hospital and later a police station, but left without being reported missing; his body was retrieved from the River Thames on 18 January 2024. The inquest concluded that he drowned, contributed to by no missing person report being made to the police. The report raised concerns about the absence of MPS guidance for frontline officers dealing with people who may be missing but have not yet been reported as such.
Metropolitan Police ServicePrime Life Limited
Margaret Florence Joyce Stringer died by suicide between 18.35 and 19.00 on 10 October 2020 in the bathroom adjoining her room at Nightingales Nursing Home. The inquest found that appropriate precautions were not taken, including the return of an item used as a ligature, and that information about her suicide risk was incomplete and insufficiently recognised. Concerns included the absence of a fail-safe system to restrict access to dangerous items and weaknesses in the collation and transfer of information about suicide risk between services.
Blackpool Teaching Hospitals NHS Foundation TrustLancashire County CouncilLancashire & South Cumbria NHS Foundation TrustNightingales Care LimitedZion Care Limited
Kieran Luke Hubbard, who had a history of depressive disorder and recurrent suicidal thoughts, was found dead on 8 February 2019 after hanging himself at a building site. The principal concerns were failures to expedite and properly coordinate an inpatient bed, failures to communicate and escalate the decision to abandon the bed search, inadequate guidance about driving during a mental health crisis, and shortcomings in the post-death investigation.
Greater Manchester Mental Health NHS Foundation TrustPennine Care NHS Foundation Trust
Stephanie Cave had a history of deteriorating mental health, self-harm and attempts to end her life, and died after being found with a ligature around her neck on 17 August 2017 while in hospital care. The concerns identified included inconsistent enhanced observations, lack of training and written guidance for conducting and recording observations, and failure to routinely record precise observation times.
Ludlow Street Healthcare Group LimitedWelsh Government
Daniel Gary Dunkley was found hanging in his cell at H.M.P. Woodhill on 29 July 2016 and subsequently died in hospital on 2 August 2016. Three referrals for a full mental health assessment had been made before his death, but none took place; the report identified concerns about the assessment process and the failure to notify the relevant unit or Mr Dunkley about an assessment scheduled for the morning he was found.
Woodhill Prison
Andrea Denise MANN was discovered hanging at her home on 10 February 2024 and died in hospital the following day after invasive medical care was withdrawn and palliative care was provided. The inquest identified concerns about limited Community Mental Health Trust involvement, the absence of a requested psychiatric appointment, delays in psychological therapy, and the lack of an overarching tool to scrutinise and measure the care provided.
Bradford District Care NHS Foundation Trust
John Charles Hazlewood died on 31 January 2017 after self-harming with hand tools and consuming a large amount of white spirit. The report identified concerns about psychiatric clinicians’ access to medical records and documentation, failure to involve his partner in assessing his escalating behaviour, monitoring of revised on-call procedures, and a lack of self-harm training for relevant hospital staff.
Leicestershire Partnership NHS TrustUniversity Hospitals of Leicester NHS Trust
Emma Jane SIMKIN, also known as Emilie Zukiard AFFIN, died on 20 February 2021 after standing in front of a freight train at Railway Lineside, Spitalgate Hill, Grantham, and receiving non-survivable injuries. The report raises concern that people may mask mental illness in front of professionals, who may accept what they are told without sufficiently considering evidence from families, and asks whether policies and training addressing this issue are adequate.
Legal Services LincolnshireLPFT Legal ServicesVine Street Surgery
Robin Damien Richards, who had a history of mental health problems and diagnoses including Asperger's Syndrome, ADHD and a learning disability, was found suspended by his belt at supported accommodation on 29 June 2015 and died in hospital on 3 July 2015. Concerns included a shortage of suitable supported accommodation, the suitability and inspection of his placement, and shortcomings in communication, handover, discharge planning, care planning and risk assessment.
Department of Health and Social CareSomerset NHS Foundation Trust
Helen England, who had bipolar affective disorder and was subject to a Community Treatment Order, was found hanging in her home on 26 December 2013 after recent self-harm, hospital discharge and concerns about her safety. The principal concern was that there was no protocol or guidance for mental health nurses on whether to refer discharge decisions to a doctor, particularly when a patient subject to a Community Treatment Order had attended or been admitted to hospital following self-harm.
Department of Health and Social Care
Yemisi Cielto-Opaleye, a psychiatric inpatient at St Pancras Hospital, died on 13 December 2023 after receiving an Olanzapine depot injection and developing Olanzapine toxicity. The report identified concerns about inadequate pre- and post-injection vital-sign monitoring, unclear staff responsibilities, insufficient escalation and contingency planning, and failures to obtain required approval and provide adequate information about risks.
North London Mental Health Partnership
David Reginald Bert Stacey died after sustaining chest injuries in a road traffic collision on 27 November 2017. Before the collision, he had been assessed under the Mental Health Act and was left alone after the assessment team departed. Concerns included a failure to communicate that a bed was available, the assessment team leaving before safeguards were in place, and the lack of an identifiable facility for cases of special urgency in Leicestershire.
Department of Health and Social CareNHS Leicester, Leicestershire and Rutland Integrated Care BoardUniversity Hospitals Birmingham NHS Foundation Trust
Jack Stephen TAYLOR was a detained inpatient who left escorted leave on 17 March 2021 and was found unresponsive at premises in Worthing on 19 March 2021, where he died despite urgent medical assistance. The report raised concerns about Mill View Hospital’s reliance on police support and failure to consider the full range of powers for returning absconded patients, as well as weaknesses in joint hospital-police AWOL and missing-person procedures that could delay locating and returning high-risk patients.
Sussex Partnership NHS Foundation TrustSussex Police
Mr Jamie Fairclough, who had complex difficulties and was receiving mental health services, was discharged from the Community Mental Health Team in November 2016 after unsuccessful attempts to engage with him. He was found dead at home on 9 December 2016 from chemical asphyxiation, and the inquest recorded a conclusion of suicide. Concerns included the discharge decision being contrary to the agreed care plan and made without meaningful consultation, and high caseloads for care co-ordinators.
Kent and Medway Mental Health NHS Trust
