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Philip Anthony Denning · Prevention of Future Deaths report View report

16 Feb 2016 Nottinghamshire H. Connor

Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

Sophie Ann Louise Cotton · Prevention of Future Deaths report View report

27 May 2025 County Durham and Darlington R. Sutton

Sophie Ann Louise Cotton had a long history of mental health problems and previous suicide attempts. On 6 January 2025, after she failed to attend important family contact and could not be contacted, four calls were made to the police requesting a welfare check; shortly afterwards, her family found her hanging by a ligature at home. The principal concerns were refusals or delays in police attendance under the “Right Care, Right Person” procedure, including where callers expressed a real and immediate risk to life and where mental health services could not enter locked premises.

Fiona May Humberstone · Prevention of Future Deaths report View report

28 Jun 2021 Essex S. Horstead

Fiona May Humberstone, who had longstanding mental health conditions, alcohol misuse and chronic pain, died at home from an inadvertent overdose of prescribed Oromorph taken with other medication. The concerns included mental health clinicians relying solely on patients’ accounts of their medication and inadequate access to accurate, up-to-date prescribing information between primary and secondary care.

ZSOLT KIRJAK · Prevention of Future Deaths report View report

24 Jun 2022 Inner West London R. Caller

ZSOLT KIRJAK died on 14 March 2021 after driving his car to a location following prolonged tinnitus, lack of sleep, anxiety and suicidal thoughts. The report raises concerns that his psychiatric assessment and suicide risk assessment were incomplete, that relevant previous self-harm was not adequately investigated, and that it was unclear whether his wife was given an opportunity to contribute to his assessments and management plan.

Nigel John KEENAN · Prevention of Future Deaths report View report

13 May 2026 Cumbria R. Cohen

Nigel John Keenan died by hanging at HMP Haverigg between 8 pm on 12 March 2025 and 4:20 am on 13 March 2025; the inquest concluded suicide. Concerns included the lack of seven-day mental health support at the prison, limited staffing for constant observation, and a possible incentive for prisoners in crisis to minimise their suicidal intent.

Mr Roberto Bottello · Prevention of Future Deaths report View report

16 Feb 2024 Inner West London F. Wilcox

Roberto Bottello, who had been experiencing depression, anxiety, panic attacks and later an acute psychotic episode, was detained under section 136 of the Mental Health Act after police found him acutely disturbed. While in a hospital cubicle, he broke the window and fell 25 feet, suffering multiple injuries including a divided axillary vein and artery; his death was announced at 07:27 on 16 September 2020. Substantive concerns included the unsuitability and inadequate safety of the cubicle, communication and information-management failures, insufficient mental-health nursing provision, confusion over his identity, limited access to section 136 suites, and wider concerns about training and psychiatric-care resources.

Kirsty Marie Doodes · Prevention of Future Deaths report View report

14 Oct 2021 Cornwall and Isles of Scilly A. Cox

Kirsty Marie Doodes, who had a history of mental ill-health, was discharged from hospital on 18 March 2020 and later deteriorated at home. She died from her injuries on 27 March 2020 after being taken to hospital. The concerns included insufficient note-keeping, inadequate detail about the future care plan and management of acute deterioration, and insufficient involvement of her carer in the discharge process.

Luke Richard WILDEN · Prevention of Future Deaths report View report

16 Jan 2022 Bedfordshire and Luton E. Whitting

Luke Richard WILDEN was a vulnerable adult with high functioning autism and ADHD who, after turning 18, was not effectively transitioned from child to adult mental health services or provided with an appropriate social care package. He moved to independent living on 2 January 2020, experienced declining mental health and drug misuse, and was found deceased in his flat on 22 May 2020 after being discharged from psychiatric inpatient care. The principal concerns were inadequate transition arrangements within ELFT and a possible wider national gap in services.

Nimo OSMAN · Prevention of Future Deaths report View report

12 Aug 2024 Inner North London I. Potter

Nimo Osman was in state detention under a Hospital Order and receiving psychiatric inpatient care when she collapsed on the ward on 21 April 2022. She was unresponsive for over half an hour before an ambulance was called and died in hospital on 23 April 2022 from hypoxic ischaemic brain injury. The principal concerns were delays in recognising the emergency and calling an ambulance, whether learning had been embedded among staff, completion of venous thromboembolism assessments, and ambiguity in the Trust’s venous thromboembolism policy.

David John Ireland · Prevention of Future Deaths report View report

27 Feb 2018 Exeter and Greater Devon L. Brown

David John Ireland experienced an acute-onset psychosis, forced entry into a house, climbed from a first-floor window while detained by residents, and sustained serious injuries in the fall. He died shortly after admission to hospital; a concern was raised that the crisis team did not advise him or his friend that he could attend the emergency department for an urgent mental health assessment.

Andrew James Naylor · Prevention of Future Deaths report View report

4 Jun 2024 County Durham and Darlington J. Richards

Andrew James Naylor was found deceased on 11 October 2022 in Durham City, the day after discharge from hospital following treatment for a drug overdose and alcohol withdrawal. The report identified concerns about inadequate warnings of the risks associated with combining the administered drug with alcohol or drugs, poor communication between services, and insufficient consideration of his homelessness, discharge safety, and available support. The inquest concluded that he died from the combined central nervous system depressant actions of alcohol and two drugs, with cumulative failures contributing more than minimally to his death.

Mr Oliver Beswetherick · Prevention of Future Deaths report View report

21 Feb 2024 Inner South London J. Morris

Mr Oliver Beswetherick, who had a history of depression, bulimia and bipolar affective disorder, was found dead after falling from his flat on 4 September 2020. The report raised concern that mental health crisis teams did not have contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, hindering direct referrals and the sharing of case information.

Olaseni Lewis · Prevention of Future Deaths report View report

28 Jun 2017 South London S. Lynch

Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.

Gordon Fenton · Prevention of Future Deaths report View report

23 Apr 2020 Manchester South A. Farrow

Gordon Fenton, a 70-year-old man detained under the Mental Health Act, developed a urinary tract infection and related complications during periods of care between psychiatric and medical services, and died in hospital on 29 June 2019 after a seizure and cardiac arrest. The principal concerns were inadequate information sharing and the lack of a formal joint decision-making process between the two NHS Trusts, with the inquest finding that this prolonged and contributed to ineffective management of his infection.

Annette Susan HEWINS · Prevention of Future Deaths report View report

24 Sep 2019 South Wales Central G. Hughes

Annette Susan Hewins was detained under the Mental Health Act on 7 February 2017 for assessment and treatment of psychotic symptoms and opiate withdrawal. She was found unconscious in hospital on 8 February 2017 and died despite resuscitation; the post-mortem identified extensive coronary artery atherosclerosis as the likely cause of death. Concerns included inconsistent clinical record-keeping, incorrectly completed NEWS charts, missed observations, inadequate documentation and requesting of an ECG, insufficient detail in observation records, and the absence of a Trust policy for managing opiate-dependent patients in acute admissions.

Kenneth Stanley Baylis · Prevention of Future Deaths report View report

29 Feb 2024 Nottinghamshire E. Didcock

Kenneth Stanley Baylis took his own life on 23 January 2023 while on unescorted leave as an informal inpatient on Kingsley Ward. The report identified concerns including inadequate suicide risk assessment and mitigation, insufficient family involvement, failure to follow planned-leave procedures, and inadequate review and investigation after serious suicide attempts or a death.

Gillian Rose Taylor · Prevention of Future Deaths report View report

11 May 2016 South Wales Central A. Barkley

Gillian Rose Taylor had a lengthy history of mental health issues and repeated suicide attempts. After being detained under the Mental Health Act and treated away from Powys because no acute bed was available locally, she remained under community mental health care until her death by hanging at home on 3 January 2016. The concerns included the lack of an acute treatment facility in Powys, resulting patient transfers, lack of continuity of treatment, and the possible adverse effect of this experience on her engagement with mental health professionals and risk of self-harm or suicide.

Hadley John Savory · Prevention of Future Deaths report View report

11 Aug 2021 North East Kent I. Brownhill

Hadley John Savory was discharged from hospital on 25 September 2019, and his presentation later declined in the community. He was found deceased at home on 13 December 2019 after toxicological evidence indicated that he had taken a lethal dose of methadone; concerns included the absence of a multi-agency planning meeting before discharge and unclear multi-agency procedures for supporting patients with concurrent health, substance misuse and social care needs.

Delwyn PREECE · Prevention of Future Deaths report View report

17 Mar 2026 South Yorkshire (Eastern) L. Slater

Delwyn Preece, a 64-year-old man, died at Rotherham Hospital on 19 August 2025 from a hypoxic brain injury following deliberate self-suspension by ligature while he was an informal patient at an acute mental health hospital. The principal concerns were repeated granting of leave without documented mental state examinations or risk assessments, poor and retrospective record-keeping, and shortcomings in the patient safety investigation arising from unfamiliarity with the medical records system.

Rachel Morgan · Prevention of Future Deaths report View report

10 Feb 2017 Manchester South A. Morris

Rachel Morgan, who had post-natal depression with psychotic symptoms and was considered at high risk of suicide, was found with a ligature around her neck on 16 April 2016 and died from severe anoxic brain injury on 24 April 2016. The principal concerns were delays in reviewing her medication, failures to update risk assessments after information about her suicide risk was received, insufficient observation levels, and a lack of clarity about observation procedures.