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Darren John Lawrence · Prevention of Future Deaths report View report

15 Oct 2021 Manchester City N. Meadows

Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.

Amy El-Keria · Prevention of Future Deaths report View report

3 Oct 2016 West Sussex P. Schofield

Amy El-Keria, aged 14, died on 13 November 2012 after tying a ligature around her neck and suspending herself from a radiator while receiving inpatient mental health care. The inquest identified concerns about staffing levels being insufficient to provide the one-to-one support in her care plan and the shortage of acute mental health beds for young people close to home, limiting family support.

STUART CHRISTOPHER JAMES BERRY · Prevention of Future Deaths report View report

12 Jan 2026 Essex S. Horstead

STUART CHRISTOPHER JAMES BERRY, who had a history of mental health issues and significant cocaine misuse, was remanded to HMP Chelmsford on 27 January 2024 after expressing an intention to end his life. He was found suspended in his cell about seven hours after arrival and died at Broomfield Hospital on 1 February 2024; the medical cause of death was hanging and the jury concluded suicide. The principal concerns included failures in mental-health care, communication and risk documentation, failure to share information about his extreme suicide risk, inadequate assessment and supervision in prison, and the accessibility of cell-window ligature points.

Carol Ann Guest · Prevention of Future Deaths report View report

5 Sep 2024 South Yorkshire (Eastern) N. Mundy

Carol Ann Guest died by suicide after hanging herself at home on 24 March 2024, before a planned consultant visit could be arranged following an urgent mental health referral. The principal concerns were inadequate crisis support for patients over 65, delays in sending and responding to the urgent referral, and the provision of a crisis number that was not available to people over 65.

Teresa Chmielek · Prevention of Future Deaths report View report

24 Nov 2023 Manchester North C. McKenna

Teresa Chmielek took her own life at home on 17 June 2023, after a referral to mental health services concerning her suicide risk was rejected without contact or a face-to-face review. The concerns included failure to identify or recognise the reported recent suicide attempt, lack of meaningful multidisciplinary discussion and direct contact, inadequate referral arrangements and documentation, and the absence of procedures and auditing for referral decisions.

Gail Ann Bannister · Prevention of Future Deaths report View report

9 Feb 2018 Worcestershire A. Cox

Gail Ann Bannister had a long history of fluctuating mental health and experienced deterioration after her father’s illness and death. She died by suicide, with the medical cause of death recorded as hanging. Concerns included that her care coordinator did not see her after appointment, undermining the intended care arrangement, and that it took several hours for her husband to reach the care team during a crisis because of a known single-phone-line problem.

Imogen Alice NUNN · Prevention of Future Deaths report View report

7 Oct 2025 West Sussex, Brighton and Hove P. Schofield

Imogen Alice Nunn died at home on 1 January 2023 after consuming a substance she had obtained approximately six weeks earlier, during a period of deteriorating mental health. The report raises concerns about failures in mental-health risk management and the shortage of British Sign Language interpreters and BSL-proficient clinicians supporting deaf patients.

Louise Asha Allen · Prevention of Future Deaths report View report

12 Jul 2022 East London N. Persuad

Louise Asha Allen, who had bipolar disorder and emotionally unstable personality disorder, was discharged from hospital in December 2020 and was regarded as a very high risk to herself. Between February and June 2021, she did not receive necessary mental state assessments or sufficient support, and inaccurate clinical details contributed to unreliable risk assessments. On 12 June 2021, she placed herself in front of a train. The principal concerns related to inadequate care coordination, including insufficient continuity of care, excessive caseloads, staff turnover and insufficient numbers of care coordinators.

John Preece · Prevention of Future Deaths report View report

15 Jan 2019 South Wales Central R. Barkley

John Preece, who had early onset dementia and was prone to seizures, suffered a witnessed seizure and fall on 9 September 2015, sustaining a serious head injury. He was not closely monitored and received incomplete and inappropriate physical and neurological observations before being admitted to hospital, where he died in the early hours of 10 September 2015. The principal concerns were inadequate falls management and neuro-observation knowledge and training, lack of forward planning and monitoring, and delayed medical assistance for medically unwell mental health patients.

Khalid Seneen Yousef · Prevention of Future Deaths report View report

23 Jun 2022 Birmingham and Solihull J. Bennett

Khalid Seneen Yousef was decapitated during a sustained knife assault at a premises in Birmingham on 4 January 2018. The report identifies concerns that a Liaison and Diversion clinician failed to recognise the perpetrator’s psychosis and refer him for mental health assessment, and that the custody-suite model lacked commissioned psychiatrists, with wider concerns about responsibility, training and supervision.

Stephen Martin ADAMS · Prevention of Future Deaths report View report

30 Nov 2015 Worcestershire G. Williams

Stephen Martin ADAMS was being cared for by the Home Treatment Team of Worcestershire Health and Care NHS Trust when he died by suicide by hanging at his home. The inquest identified that the suicide-risk assessment section of a Mental Health Liaison Team risk assessment document had not been completed, and that risk assessment was instead inferred from the worker’s actions.

Billie Jonathan LORD · Prevention of Future Deaths report View report

1 Nov 2018 Milton Keynes T. Osborne

Billie Jonathan LORD died from suicide on 11 July 2017 after suffering from psychosis, autism and a psychotic illness associated with non-prescription drug use. He had been admitted voluntarily to the Campbell Centre and was being monitored by intermittent 15-minute observations before absconding and entering the path of a high-speed train. The concern raised was that three-bed dormitory accommodation at the Campbell Centre was inappropriate and may have added to the stress experienced by the patient; a review of the accommodation was suggested.

Grahame Searby · Prevention of Future Deaths report View report

23 May 2018 West Yorkshire (Western) M. Fleming

Grahame Searby, who had extreme anxiety and depression and was under community mental health supervision, was found hanging at his home on 27 July 2017. The principal concern was that the mental health team lacked access to the GP database through EMIS, limiting information gathering about his care.

Ceara Marie Thacker · Prevention of Future Deaths report View report

30 Sep 2019 Liverpool and Wirral A. Bhardwaj

Ceara Marie Thacker, a 19-year-old University of Liverpool student with a history of self-harm and contact with mental health services, was found deceased hanging on 11 May 2018. Concerns included the lack of discussion about involving her family in care planning and the absence of attempts to cut her down after she was found hanging; the first-aid training received by the person who found her did not cover hangings.

Kieran Lavin · Prevention of Future Deaths report View report

1 Aug 2024 Birmingham and Solihull J. Bennett

Kieran Lavin, who had experienced worsening depression and suicidal thoughts, died after leaving a mental health unit with his wife for transport to another facility. Shortly afterwards, on the M5 motorway, he exited the vehicle and was struck by vehicles. The principal concerns were that critical suicide-risk information was not recorded or recorded promptly, and that the transport risk assessment and guidance for family transport were inadequate.

Rebecca Marshall · Prevention of Future Deaths report View report

24 Sep 2019 Inner South London B. Ballard

Rebecca Marshall was referred for mental health assessment after escalating self-harm, depression, anxiety and angry outbursts. After moving to university accommodation in London, there was no interagency communication between the mental health services involved in her care, and urgent referrals did not result in a senior review. She was discovered deceased in her room on 27 November 2017, and the inquest concluded that she died as a result of suicide. The principal concerns included missed opportunities in her care and inadequate arrangements for sharing information and ensuring continuity of care between trusts when she moved areas.

Ian Allen · Prevention of Future Deaths report View report

17 Aug 2020 Birmingham and Solihull L. Hunt

Ian Allen collapsed suddenly at the nursing home where he resided on 31 December 2019 and died soon after arriving at hospital. The medical cause of death was clozapine toxicity. Concerns included a high clozapine blood level not being acted upon, inadequate monitoring and dose adjustment after smoking cessation, and the absence of a system to escalate blood test results to the consultant.

Nicholas LEGER · Prevention of Future Deaths report View report

19 Jun 2023 Inner North London A. Smith

Nicholas Leger took his own life sometime between 7:30pm and 10:30pm on 20 February 2023, after learning via his solicitor that he had been charged. He had previously attempted to take his own life and had disclosed concerns about his mental health, but there had been no formal police assessment of his mental health or risk of suicide or self-harm for more than three months. The report identified a risk that people charged by Postal Charge Requisition could take their own lives where there was no formal mechanism to assess their mental health and risk at the time of charge.

SARAH LYNNE REED · Prevention of Future Deaths report View report

28 Jul 2017 London (City) P. QC

Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

Name not published · Prevention of Future Deaths report View report

21 Dec 2018 Shropshire, Telford and Wrekin J. Ellery

The deceased had a history of mental health issues, self-harm and two suicide attempts, and was in contact with mental health services until the evening of 30 April 2018 before taking her own life the next morning. Concerns included a prolonged delay in accessing IAPT counselling and difficulties with the electronic recording, risk assessment and progress-note systems.