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Lajos MANDRIK · Prevention of Future Deaths report View report

1 Apr 2026 West London R. Furniss

Lajos MANDRIK died on 13 September 2023 after hanging himself during a period when no staff member was allocated to carry out intermittent observations on Ellis Ward at Tolworth Hospital. The report’s principal concern is that general and intermittent observations appeared not to be carried out in accordance with the Trust’s policy, including the required attempt at engagement.

David Ball · Prevention of Future Deaths report View report

24 Nov 2020 Derby and Derbyshire E. Serrano

David Ball was found deceased at home on 30 June 2019 after taking methadone and venlafaxine with the intention of taking his own life following delusions and paranoia. His discharge care plan was not fully implemented, including the planned community support. Concerns included poor communication between healthcare departments with separate patient records, and no process to ensure that emails were received or acted upon.

Emma Burbury · Prevention of Future Deaths report View report

11 Nov 2021 Cornwall and Isles of Scilly A. Cox

Emma Burbury collapsed after an altercation with her partner and died in hospital on 19 September 2018; the forensic pathologist considered it possible that injuries from the altercation caused or contributed to her death, but the evidence was insufficient to establish this as probable or certain. The report identified a missed opportunity to provide treatment after her July 2017 assessment and concerns about services for people with dual diagnoses, including care coordination, communication between organisations, engagement, and discharge arrangements.

Gary Etherington · Prevention of Future Deaths report View report

26 Jun 2020 Inner South London A. Harris

Gary Etherington was found dead in his van after taking an overdose of his wife’s Amitriptyline; the inquest concluded that his death was suicide. The coroner identified failures in the mental health assessment and discharge process, including inadequate investigation of psychotic symptoms and suicide risk, insufficient communication with the GP, and an unreliable Root Cause Analysis that failed to identify these care problems.

Mark Robert Anstice · Prevention of Future Deaths report View report

16 Jan 2015 Norfolk J. Lake

Mark Robert Anstice, who had a history of mental health and social problems and previous self-harm, was found hanged on 27 September 2014. Concerns included that recommended support-worker or care-coordinator provision was not actioned, uncertainty about a carer’s assessment referral, gaps in team awareness of appointments, and difficulties supporting his attendance at group sessions due to lack of transport or means.

Abbigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abbigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 and was pronounced deceased shortly after midnight on 16 February 2022 from compression of the neck by ligature. The report describes concerns about failures in mental-health care, communication, staff training, risk assessment and discharge planning, including her discharge to supported living without an adequate plan to mitigate a known risk of self-harm.

Joshua Lewis BROWN · Prevention of Future Deaths report View report

17 Jul 2014 North East Kent R. Cobb

Joshua Lewis BROWN died on 13 June 2011 after climbing over railings at the edge of cliffs at Louisa Bay and dropping forward from the cliff. The report identified concerns about limited information-sharing and engagement between the Community Health Team and Mr Brown’s family, including the absence of a process for family members to check the accuracy of information recorded about them. It also noted that the family was not made aware of available support and information about how best to support Mr Brown and themselves.

David Paul Power · Prevention of Future Deaths report View report

18 Sep 2024 Manchester South A. KC

David Paul Power, aged 28, intentionally took his own life by hanging on 7 August 2023 after a decline in his mental health. The report found that his deterioration was exacerbated by a letter incorrectly discharging him from a neighbourhood mental health team. Concerns included differing definitions of “stability” between services, which prevented access to talking therapies, and a lack of evidence that subsequent team actions had been embedded or audited.

Melvin James and Anne-Marie James · Prevention of Future Deaths report View report

8 Sep 2017 Black Country Z. Siddique

Melvin James experienced psychotic symptoms, was admitted to hospital, and was discharged without planned psychiatric follow-up. On 8 March 2017, he fatally stabbed his sister, Anne-Marie James, injured his mother, and sustained fatal stab wounds himself. The principal concerns were missed communication about his continuing delusions, inadequate information-sharing with family, and the absence of formal referral or aftercare following discharge.

HARRY JOSEPH PENGELLY ARMSTRONG EVANS · Prevention of Future Deaths report View report

4 Nov 2022 Cornwall and Isles of Scilly G. Davies

Harry Joseph Pengelly Armstrong Evans died by hanging on 24 June 2021 during an acute mental health crisis, following academic pressures and concerns about his wellbeing. The report identified concerns about the university’s lack of proactive personal engagement, failures in safeguarding alert follow-up, insufficient staff awareness of information-sharing policies, and reliance on email and online forms to access welfare support.

Andrew Gus PEEBLES · Prevention of Future Deaths report View report

13 Jun 2016 Preston and West Lancashire J. Adeley

The circumstances of Andrew Gus Peebles’s death are said to be set out in the attached summing up, jury findings and conclusion; the inquest concluded on 18 May 2016. The substantive concerns included failures to record or undertake mental-health assessments and referrals, inadequate review of relevant documentation, and insufficient evidence of supervision or retraining after the concerns were identified.

Name not published · Prevention of Future Deaths report View report

1 Apr 2022 Manchester City N. Meadows

The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.

Magdalen Bernadette Dwerryhouse · Prevention of Future Deaths report View report

29 May 2014 Manchester West A. Walsh

Magdalen Bernadette Dwerryhouse, who lived alone and was being assessed for a paranoid mental illness, died at home on 25 November 2013 after a kitchen fire; she was found collapsed and unresponsive at the bottom of the stairs. Concerns included the arrangements for appointments with vulnerable people, the response to a failed home visit and the lack of partnership working between the mental health trust and the fire service regarding fire-risk prevention.

JAVED IQBAL · Prevention of Future Deaths report View report

3 Mar 2025 Birmingham and Solihull J. Bennett

Javed died on 1 June 2024 after deliberately igniting his room with flammable liquid and sustaining major burn injuries and smoke inhalation, followed by multi-organ failure. The report identified concerns that staff did not recognise and appropriately act on serious acute mental health issues, including not escalating worsening mood and irrational behaviour to the GP in writing. It also identified the absence of a formal internal post-death investigation and outstanding internal training that had not addressed these concerns.

Michael John Vince · Prevention of Future Deaths report View report

27 Jun 2022 East London G. Irvine

Michael John Vince, a patient of the community mental health team receiving treatment for schizo-affective disorder, was found deceased at home on 19 June 2021 after apparently taking an overdose. The concerns included prolonged prescribing of medication for insomnia, lack of meaningful prescription review, failure to share evidence of dependence, and failure to monitor the frequency of PRN administration.

James Reuben Maxwell Adams · Prevention of Future Deaths report View report

7 Aug 2015 Cornwall E. Carlyon

James Adams was found dead at home on 10 August 2012 with a plastic bag and helium cylinders, and suicide notes were found nearby. He had persistent depressive disorder, alcohol dependency and a mixed type personality disorder, and was being treated by mental health services. Concerns included the police response to a welfare concern, information sharing, shortages of acute psychiatric beds, and inadequate staffing at designated mental health places of safety.

Peter Frosdick · Prevention of Future Deaths report View report

12 Dec 2019 Norfolk Y. Blake

Peter Frosdick, who had cirrhosis and was experiencing paranoid thinking, extreme anxiety and irrational behaviour, died by hanging in his garage. The concerns raised included that his mental health was not adequately assessed beyond his alcohol dependence, that home treatment or hospital admission was not offered or explored, and that teams appeared unfamiliar with each other’s referral criteria and dismissed his GP’s concerns.

Sebastian Harry DANIELS · Prevention of Future Deaths report View report

22 Sep 2023 Hampshire, Portsmouth and Southampton R. Simpson

Sebastian Harry Daniels, who had paranoid schizophrenia and was treated with clozapine, developed severe hypertriglyceridemia and necrotising pancreatitis before dying from multiple organ failure on 4 July 2021. Concerns included the failure to escalate abnormal triglyceride results, unclear communication of required GP actions in hospital discharge summaries, delays in addressing identified deficiencies, and the requirement for patients taking clozapine to attend separate appointments for some blood tests.

Thomas Nicol · Prevention of Future Deaths report View report

30 Nov 2018 Hertfordshire G. Sullivan

Thomas Nicol, a serving prisoner at HMP The Mount, was found hanging in his cell on 21 September 2015 and died in hospital on 25 September 2015. The report raised concern that the weeks-to-months taken to transfer prisoners in acute mental health crisis to suitable secure hospitals potentially puts lives at risk.

Piotr Grzegorz Kucharz · Prevention of Future Deaths report View report

24 Nov 2015 Blackpool and the Fylde A. Wilson

Piotr Kucharz was admitted to a mental health hospital and later found unresponsive after using a cord as a ligature; he died in hospital on 12 October 2014. Concerns included the absence of an effective translation service and a lack of consistency and clarity among staff about what constituted an effective observation, including whether staff should enter a patient’s room and engage verbally.