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Andrew Ronald Hall · Prevention of Future Deaths report View report

12 Mar 2014 Teesside A. Eastwood

Andrew Ronald Hall, an inmate at HM Holme House Prison, died on 27 March 2009 after causing incised wounds to his neck in a healthcare unit cell. The concerns included inadequate communication and documentation about his mental health and self-harm risk, failures in medication administration and observation, and deficiencies in CCTV quality, monitoring and staff arrangements.

Dean Ryan CROSSMAN · Prevention of Future Deaths report View report

26 May 2022 Teesside and Hartlepool J. Wharton

On 18 June 2019, Dean Ryan Crossman was found hanging after contact with emergency and crisis mental health services following suicidal behaviour the previous evening. The report identifies ongoing concerns about out-of-hours access to second doctors for Mental Health Act assessments and delays in securing private ambulance attendance.

Emily Jayne Hartley · Prevention of Future Deaths report View report

2 Mar 2018 West Yorkshire Eastern D. Hinchliff

Emily Jayne Hartley, a serving prisoner at HMP New Hall, was found suspended from a torn bed sheet in an out-of-bounds area during exercise on 23 April 2016; her death was confirmed at the scene. Concerns included serious deficiencies in the management, monitoring and recording of self-harm and suicide prevention procedures, weak information sharing and integrated planning, poor supervision, and the lack of a suitable secure therapeutic environment for people with significant mental health problems.

Edwin Lewis O'Donnell · Prevention of Future Deaths report View report

13 Jul 2017 Liverpool and the Wirral A. Rebello

Edwin Lewis O'Donnell died on 23 October 2016 after being found unresponsive and hanging by a ligature from his cell tap; resuscitation was unsuccessful. The inquest found that his accidental death was contributed to by neglect, including failures to conduct an ACCT review, act on a referral for a mental health assessment, and escalate information that he had said he would be dead by 8.00 p.m.

Roger Clive DUGGAN · Prevention of Future Deaths report View report

7 Apr 2014 Exeter & Greater Devon E. Earland

Roger Clive Duggan, aged 61, was in a heightened anxiety state when he left the Accident and Emergency Minors Department at the Royal Devon and Exeter (Wonford) Hospital at 00.47 hours on 11 February 2013. His body was found in the River Exe on 12 February 2013 and he was confirmed deceased at 14.30. Concerns included whether initial ambulance calls were treated sufficiently seriously and whether staff had the necessary training to deal with a mental health crisis.

Dale Owen Ricardo Scott Proverbs · Prevention of Future Deaths report View report

6 Jan 2015 North London A. Walker

Dale Owen Ricardo Scott Proverbs, a patient detained under the Mental Health Act and placed in seclusion at North London Clinic, collapsed after continuous observation was not maintained and died. The report identified concerns that Partnerships In Care’s observation policies were not followed and that the applicable level of observation could be insufficient to prevent another fatality in similar circumstances.

Guy Jeffrey Robinson · Prevention of Future Deaths report View report

12 Nov 2015 Manchester North L. Hashmi

Guy Jeffrey Robinson, a 31-year-old man with mental and physical health problems, left a mental health ward on leave on 10 July 2014 and did not return. He was found deceased outdoors on 15 July 2014; the inquest found the cause of death to be multiple drug toxicity and exposure. Concerns included delay and inadequate familiarity with the AWOL protocol, and a lack of direct inpatient access to Clinical Psychology services.

George Daniel TWIDDY · Prevention of Future Deaths report View report

8 Apr 2019 Portsmouth and South East Hampshire D. Clark

George Daniel TWIDDY was found hanging from a tree on 15 November 2017 and died in hospital on 17 November 2017 after suffering an untreatable brain injury. The principal concern was a lack of clarity between the Hampshire AMHP Service and Southern Health NHS Trust’s Early Intervention Psychosis Team about responsibility for providing immediate assistance, leaving his parents and practitioners unclear about where help would come from.

Cain Alex River Donald · Prevention of Future Deaths report View report

5 Jun 2025 Oxfordshire N. Graham

Cain Alex River Donald died by hanging on 29 July 2022 after being discharged from Ashurst PICU directly into the community on 19 July 2022. The principal concerns were deficiencies in discharge planning and communication with his family and Probation Services, and failure by the Crisis Home Treatment Team to supervise medication administration and escalate concerns about compliance.

Alex Ganski · Prevention of Future Deaths report View report

15 Jun 2026 West Sussex, Brighton and Hove Joseph Turner

Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.

Phephisa MABUZA · Prevention of Future Deaths report View report

15 Jul 2024 Central and South East Kent P. Harding

Phephisa MABUZA, who had psychosis and had not taken prescribed olanzapine for several months, was found at the base of a location in Dover after apparently falling from height. He had been hearing voices before his death, but the inquest evidence did not establish how he fell or his intention at the time. Concerns included local crisis-response guidance allowing a seven-day response for some presentations when national guidance stated 72 hours, and an operational policy containing incorrect triage response codes.

Callum James Hargreaves · Prevention of Future Deaths report View report

29 May 2025 Cornwall and Isles of Scilly A. Cox

Callum James Hargreaves, who had a history of substance misuse and housing instability, was found dead in the sea on 20 January 2024 after being removed from a cliff edge and assessed under the Mental Health Act the previous day. The principal concerns were that the rationale for not pursuing a short-term admission was not recorded, and that clinicians did not further explore or test Callum’s refusal to allow his mother to be informed of his discharge. The report also noted that the Nearest Relative’s details appeared not to have been completed on the MH 1.

Joseph David POWELL · Prevention of Future Deaths report View report

17 May 2025 Cheshire S. Murphy

Joseph David POWELL, aged 28, was found suspended at his home on 6 September 2024 and did not respond to resuscitation. The principal concern was that requiring patients with mental health difficulties to book their own GP follow-up may result in missed reviews and no further medication.

Shalan Blackwood · Prevention of Future Deaths report View report

3 May 2016 Nottinghamshire S. Haskey

Shalan Blackwood died at HMP Nottingham on 5 August 2015 as a result of bleeding from a duodenal ulcer. The report identified concerns about inadequate care and supervision for prisoners with complex physical or mental health needs, insufficient staffing for prisoners in segregation requiring a four-person unlock, unclear decision-making tools, widespread use of New Psychoactive Substances, and insufficient recognition of urgent physical symptoms obscured by mental health issues.

Nora Theresa Bruton · Prevention of Future Deaths report View report

25 Mar 2019 Birmingham and Solihull A. Hodson

Nora Theresa Bruton was found face down in a pond on 15 November 2018 and was declared deceased at the scene. Post-mortem and toxicological evidence indicated death by drowning while under the influence of alcohol. The report identified concerns about insufficient assessment of the impact of increased alcohol on suicidal thinking and self-risk, lack of referral to Addiction Services, and gaps in communication and recording of crisis calls between mental health teams.

Andrew Elliot FROST · Prevention of Future Deaths report View report

12 Feb 2015 Inner North London M. Hassell

Andrew Elliot Frost, aged 34, took his own life after jumping in front of an underground train on 25 September 2014. The report identified concerns about a lack of shared understanding between the crisis team and general practitioner, incomplete recording of information, and an inadequate pager messaging service.

Benjamin James Charles MURRAY · Prevention of Future Deaths report View report

2 May 2019 Avon M. Voisin

On 5 May 2018, Ben was found beneath the Clifton suspension bridge after walking onto the bridge, climbing onto the buttress wall and propelling himself forward. The inquest concluded that his death was suicide. The report raised concerns about mental health disclosure by university applicants, the pastoral role of universities during transition to higher education, and the absence of university investigation reports following a student death.

Kimberley Smith · Prevention of Future Deaths report View report

9 Dec 2020 Surrey A. Crawford

Kimberley Smith, who had a history of mental health conditions, alcohol dependency and self-harm, died by suicide after leaving an inpatient psychiatric unit while on unescorted leave and being found with a plastic bag over her head. The concerns included inadequate risk assessment and management of alcohol use and leave, failures in observation and missing-person procedures, and the absence of clear written policies for informal and detained patients leaving the unit.

Jonathan Mark Thornton · Prevention of Future Deaths report View report

8 Apr 2026 Nottinghamshire A. Pountney

Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.

Paul Christopher THOMPSON · Prevention of Future Deaths report View report

6 Feb 2026 Suffolk D. Stewart

Paul Christopher THOMPSON died on 15 July 2024 after moving onto the railway tracks at Elmswell Railway Station and lying in the path of an oncoming freight train. He had a history of suicidal ideation and had been receiving mental health care in custody. The report identified shortcomings in the internal passage of information at HMP Norwich about the release of prisoners receiving mental health care, and in the timely provision of release information to Probation Services.