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Andrew Mark Largin · Prevention of Future Deaths report View report

25 Jan 2023 Inner North London M. Hassell

Andrew Mark Largin died by suicide after asphyxiating himself in the early hours of 6 February 2022 at the home where he lived. Concerns included delays in allocation to the neighbourhood rehabilitation team, failure by the crisis team to reassess him after being told he remained very depressed, inadequate recording and investigation of decision-making, and a lack of clarity about referral pathways and response times between teams.

Amanda Jaye Briley · Prevention of Future Deaths report View report

11 Nov 2019 Leicester City and South Leicestershire L. Brown

Amanda Jaye Briley, who had Asperger’s and a history of serious self-harm attempts, was found unconscious with trousers around her neck in a psychiatric ward on 26 December 2016 and died in intensive care on 28 December 2016. Her observation level had been reduced for Christmas leave and was not reinstated at the previous level after her return. The report also raised concern about the lack of local inpatient provision and commissioning arrangements for people with autism requiring inpatient mental health treatment.

Paris Alan George Lapper · Prevention of Future Deaths report View report

10 May 2021 West Sussex P. Schofield

Paris Alan George Lapper, aged 19, was found deceased in his room at the Wolsey Hotel on 13 August 2020 and was declared deceased at 1125hrs. The post-mortem recorded respiratory depression due to opiate and benzodiazepine toxicity. The report raised concerns that he obtained duplicate prescriptions from multiple providers because providers lacked a central record or mechanism to check prescriptions issued elsewhere, creating a risk of medication misuse and fatal outcomes.

Rosie Catherine YOUNG · Prevention of Future Deaths report View report

16 Feb 2024 Worcestershire D. Reid

Rosie Catherine YOUNG died on 8 November 2021 after sustaining a traumatic brain injury when she stepped from the rear door of a moving ambulance while being transported to a psychiatric unit. The inquest identified concerns about failures to record and communicate her previous incidents of jumping from moving vehicles, inadequate risk assessment and transport arrangements, and insufficient staff awareness and training regarding the Mental Health Act Transportation Policy.

Gary Richards · Prevention of Future Deaths report View report

9 May 2014 Inner South London A. Harris

Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

Mohammed Ashraful Islam CHOUDHURY · Prevention of Future Deaths report View report

6 Jan 2026 Bedfordshire and Luton E. Whitting

Mohammed Ashraful Islam CHOUDHURY, aged 26, died at hospital on 11 January 2023 after being attacked and stabbed by another resident at his supported accommodation. The concerns included inadequate management of the other resident’s known risks, lack of a multidisciplinary plan after he stopped taking medication, and withdrawal of medication support without checking with his GP that prescriptions were being obtained.

Sheila Ann Hadfield · Prevention of Future Deaths report View report

27 Sep 2018 Manchester South A. Mutch

Sheila Ann Hadfield, who had paranoid schizophrenia and lived in a residential care home, was found on the floor of her room and transferred to hospital, where the report states that she died from sepsis. The principal concern was that the care home struggled to meet her complex mental health needs and that there was a national shortage of suitable alternative placements.

Michael George · Prevention of Future Deaths report View report

9 Jul 2015 Inner South London A. Harris

Michael George died after developing a life-threatening hyperglycaemic condition while receiving long-term Olanzapine treatment. The report identified concerns about inadequate monitoring for diabetes, delays and insufficient urgency in transfer to A&E, incomplete referral information, and gaps in the subsequent oversight and care arrangements for the physical health of mental health inpatients.

Paul Anthony CHASE · Prevention of Future Deaths report View report

15 Oct 2024 Liverpool and the Wirral A. Bhardwaj

Paul Anthony Chase, also known as Paul Anthony Malone, was found deceased hanging in Woolton Woods, Liverpool, on 13 March 2024; the post-mortem examination found the cause of death to be hanging. He had a history of post-traumatic stress disorder and cocaine use, and the inquest concluded that he died by suicide. The report raised concerns about limited mental health, alcoholism and addiction support for veterans, including waits of up to 18 months for some services.

James John Jude Booth · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Bridgman

James Booth, who had longstanding mental ill-health and was detained at The Priory, Altrincham, absconded on 7 October 2020 and was found dead on 14 October 2020; the medical cause of death was hanging. The principal concerns were inadequate security of the ward garden, including the fence, inadequate risk assessments, and failures to communicate and document repeated incidents and emerging risk between shifts.

Khuong Lam · Prevention of Future Deaths report View report

24 Jul 2017 South Wales Central C. Woolley

Khuong Lam, a 42-year-old man with schizophrenia, died after absconding while on Section 17 leave, following a struggle involving pressure to the neck. The concerns included the lack of review or revocation of Section 17 leave when he was transferred to the Psychiatric Intensive Care Ward, the arrangements for escorts during leave, and the need to share related learning across Wales.

Rebecca Claire Pykett · Prevention of Future Deaths report View report

17 Jul 2021 Stoke-on-Trent and North Staffordshire E. Serrano

Rebecca Claire Pykett, who had a history of mental health difficulties including PTSD, was found deceased at home on 25 February 2019 after intentionally hanging herself using a tie fashioned into a ligature. The concerns identified included the absence of a system to ensure that a Care Co-Ordinator was allocated, and that the expected care co-ordinator role, including timely patient contact and care planning, was not carried out in her case. The report also describes routine allocation of consultant psychiatrists as a “box ticking” exercise to satisfy the patient record system.

Mr Nicky Raymond Reilly · Prevention of Future Deaths report View report

4 Jan 2019 Manchester North J. Kearsley

Mr Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.

Janet WILLIAMS · Prevention of Future Deaths report View report

11 Sep 2017 Inner North London M. Hassell

Janet Williams became ill in early 2016 and received mental health care, including admission and home treatment. She died by suicide at home on 8 March 2017 while suffering late onset paranoid schizophrenia. Concerns included failures to record and monitor her care plan, insufficient reviews and medical follow-up, inadequate response to family concerns, and retrospective entries in her medical records.

Benjamin Faux · Prevention of Future Deaths report View report

10 Jul 2024 Berkshire H. Godfrey

Benjamin Faux was a taught research Master's student at the University of Reading who had severe mental health difficulties, disengaged from his studies, and took his own life in his student accommodation on or around 5 August 2023. The concerns included inadequate pastoral support and monitoring, the absence of a process to ensure completion of study-suspension arrangements, unclear responsibility for resolving his academic situation, and a lack of University contact with him before his death.

Colin BLACKBURN · Prevention of Future Deaths report View report

17 Sep 2021 Worcestershire D. Reid

Colin Blackburn died at HMP Hewell on 6 July 2019 after spending 15 days on remand and having been found with a ligature around his neck on three prior occasions. Concerns included multiple accepted failings in the management of his ACCT suicide and self-harm risk, and uncertainty about the correct process for urgent mental-health referrals, particularly at weekends.

KEVIN CONRAD GALE · Prevention of Future Deaths report View report

6 Nov 2023 Cumbria K. Gomersal

Mr Kevin Conrad Gale died at home on 4 March 2022; the inquest concluded that his death was suicide following deliberate self-suspension. He had a history of severe depression and anxiety and remained anxious about his Universal Credit application. The report raised concerns that DWP procedures, including lengthy forms, telephone queues and travel requirements, may be impractical or exacerbate symptoms for people with mental health illness.

Lorna Frances Cullen · Prevention of Future Deaths report View report

11 Mar 2014 Mid Kent and Medway A. Summers

Lorna Frances Cullen died after falling from the upper level of a multi-storey car park on 23 December 2012, following attendance at an emergency department where she left before receiving a mental health assessment. The principal concern was the long-term adequacy of liaison psychiatry nurse staffing in hospital emergency departments, as patients requiring assessment were regularly waiting well beyond the standard two-hour period.

Jamie Peter Norman PILKINGTON · Prevention of Future Deaths report View report

22 Feb 2024 Staffordshire and Stoke-on-Trent A. Barkley

Jamie Peter Norman PILKINGTON died after his vehicle left the road, struck a tree and caught fire in the early hours of 12 March 2023. At the time, he was under the care of Mental Health Services and had been expressing suicidal thoughts. Concerns included failures to complete suicide risk assessments and insufficient exploration and management of issues relevant to his suicide risk during mental health assessments.

Maureen Margaret Jarvis · Prevention of Future Deaths report View report

11 Sep 2019 Staffordshire South A. Haigh

Maureen Margaret Jarvis was detained at the George Bryan Centre and taken to hospital on 15 August 2018, where she died on 17 August 2018 from the effects of a burst ulcer. The report raised concerns that she did not receive a full physical examination during her admission, and also identified issues with record-keeping and the level of personal care.