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Roseanne Cooke · Prevention of Future Deaths report View report

10 Nov 2014 Manchester South J. Kearsley

Roseanne Cooke experienced a marked deterioration in her mental health, including suicidal thoughts, and was found having taken her own life at her mother’s home on 1 May 2014. The report identified concerns about unavailable inpatient psychological input, confusion and delays regarding psychological-service referrals, the absence of the Recovery Team from a discharge-planning meeting, and inadequate communication of the family’s concerns about her safety.

Amy Grace Pugh · Prevention of Future Deaths report View report

12 Jan 2026 East Riding and Hull P. Marks

Amy Grace Pugh took an overdose of drugs around midnight on 10 April 2024 and died on the morning of 11 April 2024; the inquest could not determine her intent. Concerns included clinical staff being unable to access important mental-health records from partner NHS institutions and overnight observations that did not involve entering her room or physically examining her.

Rebecca Jane Hursey · Prevention of Future Deaths report View report

9 Mar 2020 Inner West London F. Wilcox

Rebecca Jane Hursey died at St George’s Hospital on 4 May 2018 after taking an aspirin overdose while detained under Section 3 of the Mental Health Act and receiving care on the Avalon Ward. The report identifies concerns about suicidal-risk information not being verbally communicated during handover, observations and searches not mitigating her self-harm risk, and the prolonged failure to find a suitable alternative placement.

Dominic Robert Noble · Prevention of Future Deaths report View report

1 Jul 2022 West Yorkshire Eastern K. McLoughlin

Dominic Robert Noble was remanded to HMP Leeds on terrorist charges and died there on 15 August 2020 as a result of suicide. He had been identified as requiring psychiatric assessment, but remained on a waiting list without an appointment. Concerns included the adequacy of psychiatric provision at HMP Leeds, delays in accessing psychiatric assessment, and the possibility that limited resources discouraged referrals.

Timothy John Smedley · Prevention of Future Deaths report View report

16 Nov 2017 Manchester North L. Hashmi

Timothy John Smedley was found in a shallow waterway at the foot of Rakewood Viaduct on 7 June 2017, and his death was concluded to be suicide. The concerns identified were a lack of joint access to NHS records for out-of-hours services, fragmentation of care, and difficulties for people with alcohol addiction in accessing timely and appropriate mental health services.

Samuel Joseph Gomm · Prevention of Future Deaths report View report

1 Jun 2022 South Wales Central G. Hughes

Samuel Joseph Gomm, who had chronic mental ill health exacerbated by periods of alcohol abuse, died after deliberately self-inflicting lacerations to his neck at home on 3 June 2019. The principal concerns related to the WARRN risk-assessment tool: its format, accessibility and presentation could make fluctuating self-harm risks difficult for new or infrequent users to identify, potentially resulting in under-estimation of risk and sub-optimal mitigating measures.

Lucy Anne Walles · Prevention of Future Deaths report View report

22 Jun 2023 Berkshire H. Connor

Lucy Anne Walles died in hospital on 23 February 2022 after jumping from a bridge on 16 February 2022. She had mild learning disabilities and a history of self-harm, and had recently disclosed thoughts of jumping from the bridge. The principal concerns related to safeguarding, mental health provision, and inter-agency communication, including the handling of safeguarding referrals and the provision of support after her contact with mental health services.

Harry David HALL · Prevention of Future Deaths report View report

1 May 2024 Northumberland A. Hetherington

Harry David Hall, who had a history of depression and recent suicidal ideation, was found dead in the rear garden of his home on 29 May 2023 after sustaining a self-inflicted traumatic head injury from a captive bolt gun. The principal concern was inadequate record keeping about the missed mental-health appointment and the lack of clarity about whether any assessment took place before his death; the report also noted delays in appointments.

Nicholas J D’Ourou · Prevention of Future Deaths report View report

11 Feb 2025 Inner North London R. Brittain

Nicholas J D’Ourou, who had been admitted to Highgate Acute Mental Health Centre as a voluntary patient, was found on 15 April 2024 with a ligature around his neck and died from asphyxiation. The report raises concerns about inconsistent practice and limited guidance for cross-titrating psychiatric medication, and about the lack of patient observation, including electronic monitoring, in psychiatric wards.

Marjorie Grayson · Prevention of Future Deaths report View report

16 May 2022 South Yorkshire (Western) A. Combes

Marjorie Grayson died by suicide on 3 September 2020 after falling from a first-floor bedroom window at her home. The report identified concerns about the use of a hospital order without additional restrictions, inadequate consideration of the seriousness of her previous offence and impulse-control risks, limited face-to-face contact after discharge during the Covid-19 pandemic, and insufficient support and communication for her family.

Donna Levy · Prevention of Future Deaths report View report

31 Aug 2023 East London G. Irvine

Donna Levy was admitted to hospital critically unwell after severe self-neglect, with extensive skin lesions, an infected pressure sore, oedematous and ulcerated lower limbs, and clinical signs of sepsis and acute kidney injury. She underwent surgical debridement but died in hospital on 14 December 2022 from complications associated with the pressure sore. Concerns included the failure to escalate her care despite deteriorating health, the absence of a formal Mental Capacity Act assessment or mental health referral, and the decision not to undertake a Serious Investigation.

Oliver Hamlin · Prevention of Future Deaths report View report

15 Aug 2016 Avon M. Voisin

Oliver was found dead hanging from a tree at Norton Wood, Clevedon, after expressing paranoid thoughts and being triaged by the Primary Care Liaison Service. The concerns raised were that no risk assessment was carried out during triage, risk assessments should be documented, and weekend cover for the service should be considered.

John Ioannou · Prevention of Future Deaths report View report

6 Jan 2015 North London A. Walker

On 4 April 2014, John Ioannou fatally injured himself after jumping from a window at his home. The report identified a concern that there was no guidance for GPs when a patient was not collecting medication required to treat a mental health condition, and that this information was not available to the Mental Health Team.

Mr Philip Anthony Dean · Prevention of Future Deaths report View report

15 Apr 2014 Inner West London F. Wilcox

Mr Philip Anthony Dean, who had chronic depressive illness and had become suicidal, jumped from Battersea Bridge into the River Thames on 13 August 2013 and died after being recovered and resuscitated. The principal concerns included inadequate continuity of care, discharge from the Home Treatment Team before psychology referral could be made, failure to record and communicate the GP’s concerns, insufficient assessment by medically qualified personnel, apparent under-resourcing, and an inadequate serious untoward incident investigation.

CHRISTOPHER JONATHAN HIGGINS · Prevention of Future Deaths report View report

24 Dec 2015 Norfolk J. Lake

Christopher Jonathan Higgins died on 2 July 2013 after sustaining a head injury when he dived over railings while being taken outside for a cigarette at the Fermoy Unit. The report identified concerns about staff understanding of patient observations, patient transfers involving other services, risk assessment of the environment, and arrangements for detained patients requiring assessment and treatment at A&E.

Michael Harry WORRALL · Prevention of Future Deaths report View report

22 Apr 2014 Inner North London R. Brittain

Michael Harry Worrall had longstanding mental health issues and was admitted to secure forensic units before being discharged to community services in July 2013. He died after falling from a bridge in October 2013. The principal concern was the limited availability of psychological therapy at Avesbury House and the possible adverse consequences of discontinuing psychological input before discharge into the community; the report states there was no evidence that this lack of treatment contributed to his death.

CALLAN NORMAN COLLINS ATKINS · Prevention of Future Deaths report View report

26 Jun 2025 Gloucestershire R. Wooderson

Callan was found hanging at his home on 18 May 2023 and was confirmed dead at the scene. The report identified a missed opportunity for a face-to-face mental health assessment the previous day, although it found no possible or probable contribution to his death from this. Concerns were raised that crisis-team staff capacity could determine whether patients were assessed when clinically needed, and that additional resources might not be explored when the team lacked capacity.

Richard Burgess · Prevention of Future Deaths report View report

19 May 2021 Sunderland D. Winter

Richard Burgess died at Holy Cross Nursing and Residential Care Home, Sunderland, on 30 November 2018 after being punched three times in the head by another patient on 31 August 2018. The principal concerns related to dementia care, including multidisciplinary staffing, proactive assessment and risk management, family engagement, person-centred care, and converting policy into practice.

Alice Anne McMeekin · Prevention of Future Deaths report View report

4 Jun 2015 Cumbria D. Roberts

Alice Anne McMeekin was fatally attacked with a hatchet at an address in Newton Street, Millom, Cumbria, on 8 June 2013, sustaining fatal head injuries. The report raises concerns about police information not being fully shared with the ambulance and psychiatric teams, and about the assessment and discharge of the attacker despite information indicating significant risks and possible mental disorder.

Alice MEAD · Prevention of Future Deaths report View report

24 Jun 2015 Brighton and Hove V. Hamilton-Deeley

Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.