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Gwilym Emrys PRICE · Prevention of Future Deaths report View report

10 Jul 2020 Staffordshire South A. Haigh

Gwilym Emrys PRICE suffered deteriorating mental health after a physical injury and was found hanging at his home on 25 February 2020; he died later that day in hospital. Shortly before his death, his GP referred him to MPFT without using its approved referral form, which could result in incorrect prioritisation in other cases.

Daniel Mark Edward TUCKER · Prevention of Future Deaths report View report

29 Feb 2024 Nottinghamshire M. Wall

Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.

Gemma Elizabeth Azhar · Prevention of Future Deaths report View report

11 Feb 2020 West Sussex B. QC

Gemma Azhar self-referred to the Time to Talk service while experiencing long-term anxiety and depression and acute distress related to marital problems. Her assessment appointments were cancelled twice; after the second cancellation, she was discharged without an assessment of her current mental state or risk. She was later found hanging at her home, and the inquest concluded that she died by suicide. The report raised concerns that repeated cancellations and communication solely through administrators could leave people at risk, and that the relevant procedure was not consistently documented or communicated.

Andrew Goldstraw · Prevention of Future Deaths report View report

21 Feb 2020 Central Hampshire S. Burge

Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.

Sobia Tabasim Khan · Prevention of Future Deaths report View report

16 Feb 2024 Derby and Derbyshire C. Goldstone

Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

George Kyriacos Petrou · Prevention of Future Deaths report View report

25 Oct 2024 Inner North London I. Potter

George Kyriacos Petrou was found deceased in his cell at HMP Pentonville on 1 March 2021 after partially suspending himself by ligature in the bathroom of his cell. The report raised concerns that some mental health in-reach staff placed significant weight on prisoners declining suicide watch or ACCT measures, contrary to guidance, policy and procedures, and that insufficient reassurance was provided that this had been addressed.

Richard Geraint Griffiths · Prevention of Future Deaths report View report

14 Sep 2023 North Wales (East and Central) K. Robertson

Richard Geraint Griffiths moved to the Conwy area in October 2022 to live with his mother, and the transfer of his care from the South Gwynedd Community Mental Health Team did not occur. He was found suspended on 26 March 2023 and was pronounced deceased at the location; the inquest concluded suicide. Concerns included deficiencies in the Health Board’s investigation, an unfinished transfer-of-care process, and delays in implementing electronic mental-health patient notes.

Drew Howe · Prevention of Future Deaths report View report

15 May 2023 Manchester South C. Morris

Drew Howe was found dead on 19 October 2022 in a lorry on the A18 in Lincolnshire, having suspended himself by the neck with a ligature. He had experienced a deterioration in his mental health and was awaiting further assessment after being discharged without a diagnosis or treatment plan; concerns were raised that the Trust’s investigation did not fully examine his contacts with mental health services or derive all available learning.

Paul Leslie HYDE · Prevention of Future Deaths report View report

5 Dec 2014 Brighton and Hove V. Hamilton-Deeley

Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

Surendrakumar Patel · Prevention of Future Deaths report View report

10 Mar 2026 Worcestershire J. Puzey

Surendrakumar Patel died at Alexandra Hospital, Redditch, on 31 October 2024 after collapsing with a lower respiratory tract infection, with self-neglect through malnutrition contributing to his death. While on remand at HMP Hewell, he stopped eating, expressed that he no longer wished to live, lost weight, and developed acute kidney injury. The report identified concerns about healthcare staff’s failure to recognise the need for a timely mental capacity assessment, consider hospital transfer and expedited senior medical and psychiatric assessment, and consider family contact; prison staff also lacked awareness of procedures for informing or consulting next of kin about food refusal.

Julie Margaret Rose · Prevention of Future Deaths report View report

14 Dec 2015 Central and South East Kent C. Morris

Julie Margaret Rose, who had long-standing depression, anxiety and Obsessive Compulsive Disorder, was found dead at home on 26 April 2015 after unsuccessful attempts by mental health services to contact her and a delayed police welfare check. The concerns were that the Trust’s protocol was insufficiently clear about when a police welfare check was mandatory for high-risk patients, and that a shift co-ordinator was not familiar with the protocol despite it having been reinforced.

Neil Peter Bastock · Prevention of Future Deaths report View report

1 Nov 2021 West Yorkshire Eastern K. McLoughlin

Neil Peter Bastock, who had a history of paranoid schizophrenia and previous suicide attempts and self-harm, died by suicide on 20 September 2021. The report raises concerns about rescinding his detention without family involvement or a formal capacity assessment, inadequate care planning and continuity, failures to respond to warning signs after he became a voluntary patient, and failure to notify police when he left the ward.

Daniel Young · Prevention of Future Deaths report View report

26 Jul 2018 Inner West London S. Radcliffe

Daniel Young, a fit and healthy university lecturer, was randomly attacked on his way to work on 19 January 2016 and sustained a fatal stab wound to the abdomen. The report raised concerns that GP surgeries did not routinely monitor whether psychiatric patients collected their antipsychotic medication, despite the risk that stopping treatment could lead to relapse and harm to others.

Doreen England · Prevention of Future Deaths report View report

23 Jul 2015 Birmingham and Solihull L. Hunt

Doreen England, an 81-year-old woman with vascular dementia, developed a severe pressure sore during her admission to Rosemary Suite from 20 July 2014 and died on 30 September 2014. The principal concerns were the failure to prepare and implement a care plan despite her high risk, inadequate staff knowledge and training about pressure sore prevention, and insufficient ward leadership and medical cover.

Emily Jane CALDICOTT · Prevention of Future Deaths report View report

23 Mar 2022 Worcestershire D. Reid

Emily Jane Caldicott was admitted to hospital after an overdose and was later found unresponsive after tying a ligature around her neck. She died on 23 March 2020 from pneumonia and cerebral anoxia due to the application of a ligature. The principal concerns were that staff failed to adequately assess her capacity regarding Lorazepam, did not administer it in her best interests, and failed to remove the item used to make the ligature; the jury found these failures probably or possibly contributed to her death and identified a risk of future deaths.

Melvyn Lee BLOUNT · Prevention of Future Deaths report View report

21 Sep 2023 Derby and Derbyshire S. Evans

Melvyn Blount experienced a rapid deterioration in his mental health, including confusion and delusional thoughts, and died from asphyxiation on 14 January 2023 after tying a ligature. Concerns included the lack of a clear policy for ensuring that drug alerts are communicated when a non-prescriber requests a prescription from a GP who does not see the patient, and uncertainty about responsibility for informing the patient.

Sophia Ayuk · Prevention of Future Deaths report View report

20 Jan 2023 East London G. Irvine

Sophia Ayuk, who had treatment-resistant schizophrenia and was an inpatient, became motionless and unresponsive on 18 March 2022, later deteriorated and died despite resuscitation. The inquest narrative attributed her death to a pulmonary embolism following a deep vein thrombosis, and recorded that she had not taken food or drink for at least two days. The principal concerns were that VTE risk was not assessed during either period of inpatient care and that food and fluid intake monitoring was not adequately followed.

Clarice Beverley Hilton · Prevention of Future Deaths report View report

2 Jun 2016 Manchester West R. Griffin

Clarice Beverley Hilton, who had depression and anxiety, was admitted to a psychiatric unit after refusing food, fluids and prescribed medication. She refused physical observations after the first evening, became unresponsive following a deterioration in her physical health, and died on 23 January 2016 after transfer to hospital. The principal concern was the absence of policy or guidance for monitoring and responding when psychiatric patients refuse physical observations and MEWS assessment.

Matthew Gerard Craven · Prevention of Future Deaths report View report

22 Nov 2018 Manchester South A. Mutch

Matthew Gerard Craven was found dead at home on 19 April 2018 after consuming pregabalin in excess of his prescribed amount; toxicology showed a fatal dose of pregabalin. Concerns included repeated rejected referrals for psychiatric assessment, the absence of a challenge or escalation process, no agreed timescales for routine appointments, limited documentation of referral decisions, and inadequate sharing and review of mental health information.

Jean Pike · Prevention of Future Deaths report View report

7 Mar 2025 Swansea and Neath Port Talbot K. Heaven

Jean Pike, who had suicidal thoughts and intended to hang herself, was left unattended for between 20 and 45 minutes in her supported living accommodation and was then found suspended and declared deceased on 18 May 2022. The concerns included hospital discharge decisions made without multidisciplinary consultation with community professionals, inadequate consideration of risks, and an inadequate safety plan before Jean was left unattended.