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William Myers · Prevention of Future Deaths report View report

19 Jan 2018 Manchester West K. McLoughlin

William Myers, aged 79, was unlawfully killed; the medical cause of death was multiple stab wounds. The principal concerns related to inconsistent and inappropriate community care of his attacker, including failures to coordinate treatment, recognise warning signs, share relevant information, act on recommendations for Mental Health Act assessment, and maintain adequate records.

Abdullah Popalzai · Prevention of Future Deaths report View report

5 Feb 2024 Inner North London S. Bourke

Abdullah Popalzai was a remand prisoner at HMP Pentonville who was found hanging in his cell on 29 November 2019, and his death was confirmed by paramedics. He had acute psychosis and required transfer to a psychiatric unit, but no suitable bed was available for a prolonged period. The principal concern was that acutely psychotic prisoners refusing treatment were being left untreated and at risk of deterioration because suitable psychiatric hospital beds were not becoming available in a timely way.

Sasha Sabrina FORSTER · Prevention of Future Deaths report View report

23 May 2019 Central Hampshire D. Reid

Sasha Sabrina FORSTER, a 20-year-old woman with a lengthy history of mental health disorders, self-harm and overdoses, died by suicide following deliberate ingestion of a fatal overdose of Propranolol tablets. The inquest identified concerns that hospitals and police forces were not always aware of their powers and responsibilities when her section 17 leave was revoked, or had not agreed and updated a common plan, resulting in inconsistent actions and an increased risk to Sasha.

SOL HADHASSEH (FORMERLY KNOWN AS JUDITH ELVIRA SARKADY) · Prevention of Future Deaths report View report

17 Jun 2014 Norfolk D. Osborne

Sol Hadhasseh had a complex mental health history and was found unresponsive at her flat on 28 November 2013 after concerns were raised for her welfare. The inquest concluded that she had killed herself, with the medical cause of death recorded as tramadol toxicity; concern was raised that her transfer between mental health trusts had not been arranged through a direct Trust-to-Trust referral.

Carl Garry Thompson · Prevention of Future Deaths report View report

16 May 2023 Manchester South A. Morris

Carl Garry Thompson died from a drug overdose while on leave from Arden Ward, Stepping Hill Hospital, and was likely to have died on the night of 9 March 2022. Concerns included inadequate risk assessments and planning for his leave, insufficient response and escalation after family concerns about increased risk, and failure to provide a face-to-face Community Mental Health Team assessment or allocate a care coordinator before leave.

Mr Thomas Antony Smith · Prevention of Future Deaths report View report

16 May 2022 Bedfordshire and Luton T. Stoate

Mr Thomas Antony Smith died in a drugs-related death after serious failings in his care on Coral Ward during the night of 29–30 December 2020. The principal concerns were inadequate staff knowledge about the dangers and presentation of drugs, insufficient observation and escalation after a positive drugs test and signs of deterioration, and weaknesses in the system for assessing risks associated with Section 17 leave.

Paul Ashley Barton · Prevention of Future Deaths report View report

14 Oct 2021 Nottinghamshire G. Clow

Paul Ashley Barton experienced significant distress, personality changes, dysfunctional behaviour, possible paranoid or delusional thoughts, and repeated suicidal thoughts and acts. He died by hanging on 28 November 2020. Concerns included the Crisis Resolution Home Treatment Team’s focus on avoiding inpatient admission, reliance on patients’ expressed intentions or denials despite fluctuating suicidal intentions, and shortcomings in the Trust’s investigation of his death.

Roy Keith MORRIS · Prevention of Future Deaths report View report

29 Mar 2021 Buckinghamshire C. Butler

Roy Morris was found deceased in Birch Wood on 30 June 2019, having probably hanged himself there on the night of 26/27 May 2019. At the time, he was under the care of community mental health services after discharge from inpatient care. The substantive concerns were the absence of a detailed written care plan, the late allocation of a care coordinator, and insufficient opportunity for his family to engage with the inpatient team.

Barbara Ann WOODMAN · Prevention of Future Deaths report View report

22 Dec 2023 Surrey D. Stewart

Barbara Ann WOODMAN was found deceased at her residence on 31 March 2021 after police attended following concerns for her welfare. The post-mortem determined that she died from Paracetamol, Codeine and Amlodipine toxicity, having also consumed alcohol. Concerns included missed opportunities to obtain collateral information, the handling of a risk form, care planning and record-keeping, communication between inpatient and community teams, and information-sharing systems.

John Peter RICHARDSON · Prevention of Future Deaths report View report

8 Mar 2019 West Sussex P. Schofield

John Peter Richardson was admitted as a voluntary patient to Meadowfields Hospital with suicidal thoughts and went missing after leaving the hospital grounds on 3 February 2018. His body was found in woodlands on 4 February 2018, and death was confirmed at the scene. The report identified concerns including the absence of a further risk assessment and care plan, poor communication and record keeping, and confusion about his leave arrangements.

Tracey Lynch · Prevention of Future Deaths report View report

6 Jun 2016 Blackburn, Hyndburn and Ribble Valley M. Singleton

Tracey Lynch, who had emotionally unstable personality disorder, died by suicide after hanging herself in her room at Oswald House on 9 October 2015. The report identified concerns about the lack of a final discharge meeting, familiarisation visits and appropriate escorted transport, and about the absence of adequate assessments and care planning after her presentation changed and she was transferred between services.

Archi Johnson · Prevention of Future Deaths report View report

26 Jul 2022 Exeter and Greater Devon A. Longhorn

Archi Johnson, who had a history of depression, self-harm and suicidal ideation, was admitted voluntarily to a hospital ward on 5 November 2019 after reporting intrusive thoughts of taking his own life. He was found hanging on 7 November 2019; concerns were raised that information about a previous similar suicide attempt was not clearly recorded or shared, which may have affected decisions about his risk level, observation level and the removal of potentially dangerous ligature items.

Shaun Kenny HALL · Prevention of Future Deaths report View report

30 Jan 2025 Northamptonshire A. Pember

Shaun Hall had mixed anxiety, depressive disorder and emotionally unstable personality disorder, and was found deceased on 14 December 2023 after hanging himself. A referral to the Urgent Care and Assessment Team was declined despite information about escalating factors and his statement that he would take his own life if not allowed to see his children. The identity of the person who declined the referral was unknown and no notes were made of it.

Callie Lewis · Prevention of Future Deaths report View report

3 Dec 2019 Central and South East Kent P. Harding

Callie Lewis had chronic suicidal ideation and was actively planning to end her life, later dying by carbon monoxide poisoning after travelling to a remote location. The inquest concluded that her death was suicide by carbon monoxide poisoning contributed to by neglect. A substantive concern was that an online pro-suicide forum provided advice on methods of suicide and on misleading mental health professionals, frustrating assessment and enabling her to take her life.

Lucasz Lewandowski · Prevention of Future Deaths report View report

15 Oct 2014 Manchester (North) L. Hashmi

Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

Nicholas James STOUT · Prevention of Future Deaths report View report

15 Jun 2023 County Durham and Darlington J. Thompson

Nicholas “Nicky” Stout died at Darlington Memorial Hospital on 26 July 2021 after consuming a large quantity of cocaine, with acute cocaine toxicity and coronary artery atheroma recorded as factors. The report raised concerns about delays in mental health crisis assessment, incomplete crisis-team triage tools, safeguarding referrals for children, and the absence or incomplete use of safety plans.

Louise Elizabeth Amy Crane · Prevention of Future Deaths report View report

23 Jun 2025 Inner North London I. Potter

Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action plan.

Winbourne Gregory Charles · Prevention of Future Deaths report View report

28 Apr 2023 East London G. Irvine

Winbourne Gregory Charles was found unresponsive on 10 April 2021, suspended on a mental health ward, after being admitted under the Mental Health Act following an attempt to take his own life. The principal concerns included failures in risk assessment, observation practices, emergency response, record keeping, and governance processes.

James CAMPION · Prevention of Future Deaths report View report

20 Dec 2023 Liverpool and the Wirral A. Bhardwaj

James Campion, aged 57, died after consuming mirtazapine and alcohol following contact with the Psychiatric Crisis Team about taking an overdose. An ambulance was not allocated until six hours after the initial call, and he was found deceased at home when the crew arrived. The principal concerns were delays in mental health assessment, call triage and ambulance dispatch, alongside inadequate family contact information and limited family involvement.

Najib Ahmed NAAGI · Prevention of Future Deaths report View report

19 May 2026 Inner North London M. Hassell

Najib Naagi was found unresponsive in his mental health hospital bed on 3 January 2025, was resuscitated, and died in intensive care the following day from natural causes. The report raises concerns that observations were not conducted at the required times and that the clinical support worker’s records did not accurately reflect the observations made, misleading the court and undermining confidence in patient records.