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Thomas Daniel RUGGIERO · Prevention of Future Deaths report View report

24 Mar 2026 Kent and Medway I. Potter

Thomas Daniel Ruggiero, a 39-year-old prisoner at HMP Swaleside, was found unresponsive in his cell on 16 November 2024 after ligaturing and died later that day following attempts at treatment and resuscitation. The principal concern was that healthcare or mental health team attendance at ACCT reviews was not consistently secured, creating an ongoing risk for vulnerable prisoners relying on those processes as a safety-net and protective factor.

Rebecca Alice Fisher · Prevention of Future Deaths report View report

15 May 2023 Manchester South A. Mutch

Rebecca Alice Fisher was found deceased by her family on 15 April 2022 after being reported missing from a mental health ward following unescorted leave. A post-mortem found a fatal dose of drugs, including pregabalin. The principal concern was that Greater Manchester Police did not assess her as a high-risk missing person, resulting in delays to mobile telephone enquiries and specialised input; concerns also included gaps in staff understanding, documentation, information sharing, and the implementation of training and guidance.

KATHARINE ANNE FOX · Prevention of Future Deaths report View report

7 Dec 2023 Essex S. Simblet

Katharine Fox died by hanging in October 2022 after being discharged from hospital, having been unable to access community psychology services during the following months. Concerns related to the lack of handover and continuity between hospital and community psychology services, substantial waiting times, and possible inability of clinicians to access notes held on different computer systems.

Caitlin Rachel Imber ("Caiti") · Prevention of Future Deaths report View report

24 Oct 2025 North Wales (East and Central) J. Gittins

Caitlin Rachel Imber (“Caiti”) died on 13 December 2022; the recorded cause of death was hanging. The report raises concern about a 42-day delay in progressing a CAMHS referral after missing contact information was not followed up, although it states that this was not contributory to Caiti’s death.

Mr Luke Alexander Worrell · Prevention of Future Deaths report View report

21 Feb 2025 London South A. Harris

Mr Luke Alexander Worrell, who had treatment-resistant schizophrenia and was taking Clozapine, developed persistent vomiting, dehydration and an ileus before suffering a ruptured oesophagus and dying in hospital on 2 January 2021. The report identified concerns about clinical staff failing to recognise the potentially fatal gastrointestinal side effects of Clozapine and about the inappropriate use of a community treatment order instead of continued detention under a mental health section. The inquest narrative also described failures to recognise the need for face-to-face psychiatric assessment after his deterioration following discharge.

Thomas Martin Gallagher · Prevention of Future Deaths report View report

11 Aug 2016 Greater Manchester (North) L. Hashmi

Thomas Martin Gallagher, aged 16, died by hanging after leaving home on 10 July 2015 and being found suspended from a tree in a nearby park the following morning. The report identified concerns about police handling of the missing-person call, including 14 unexplained delays, failure to allocate the incident or contact the family during the initial hour, inadequate staffing, and failures to follow relevant procedures.

Andrew Paul SHIRLEY · Prevention of Future Deaths report View report

27 Jan 2023 Worcestershire D. Reid

Andrew Paul Shirley, a 25-year-old prisoner at HMP Hewell, was found unresponsive in his cell on 23 March 2021, suspended by a ligature, and was pronounced dead at the scene. The inquest found that healthcare and mental healthcare staff failed to sufficiently identify, manage, and share information about his risk of suicide and self-harm, and that these failures probably caused or contributed to his death. Concerns were also raised about staff training on suicide and self-harm risk and the Initial Segregation Health Screen process.

Thomas Josef Green · Prevention of Future Deaths report View report

16 Feb 2017 Manchester South J. Kearsley

Thomas Josef Green died at home on 10 June 2016; the medical cause of death was asphyxiation secondary to hanging, and the inquest concluded that he had taken his own life. The principal concerns related to unclear or unactioned psychiatric referral, lack of psychiatric follow-up and treatment for complex PTSD after discharge, referral to an unsuitable service, and a commissioning gap for complex PTSD services.

Matthew Alexander CASEBY · Prevention of Future Deaths report View report

22 Apr 2022 Birmingham and Solihull L. Hunt

Matthew Caseby was detained under the Mental Health Act after being found on railway lines and in a school playground, and was transferred to the Priory Hospital in Birmingham. He absconded from the hospital courtyard on 7 September 2020 after being left unattended, and was fatally injured after stepping in front of a train on 8 September 2020. The principal concerns included inadequate recording and communication of absconding risks, failure to update risk assessments, lack of a courtyard observation policy and risk assessment, and inadequate courtyard safety.

Nichola Jane Lomax · Prevention of Future Deaths report View report

17 Dec 2021 Manchester North J. Kearsley

Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.

Rosario CORDERO-SANZ · Prevention of Future Deaths report View report

29 Oct 2018 Inner North London M. Hassell

Rosario (known as Charo) Cordero-Sanz died after jumping in front of a train at Bethnal Green Underground Station on 14 July 2018. The concerns included gaps in special police officers’ access to information, understanding of missing-person and mental-health procedures, communication with a non-native English-speaking friend, and the failure to identify her as a high-risk missing person.

Janet Silva Müller · Prevention of Future Deaths report View report

4 Jul 2017 West Sussex P. Schofield

Janet Silva Müller, a patient detained under Section 2 of the Mental Health Act 1983 at Millview Hospital, died on 13 March 2015 after being found in the boot of a burning car; the circumstances were recorded as unlawful killing following her absconding from hospital. The principal concerns were incomplete and contradictory records, handovers, risk assessments and care plans, inadequate staffing, and insufficient measures to prevent detained patients from absconding.

Gareth Michael Etchells-Heights · Prevention of Future Deaths report View report

20 Nov 2023 South Yorkshire (Western) A. Pountney

Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.

John Anthony Delahaye · Prevention of Future Deaths report View report

18 Dec 2018 Birmingham and Solihull E. Brown

John Anthony Delahaye was found dead in his cell at HMP Birmingham on 5 March 2018 after taking an insulin overdose. The report identified concerns about the clarity and use of medication risk assessments, incomplete medical records, the absence of healthcare involvement in ACCT reviews, and the failure to carry out a welfare check when his cell was unlocked.

Rohan Dayal Singh · Prevention of Future Deaths report View report

30 Apr 2021 East London G. Irvine

Rohan Dayal Singh died on a mental health ward on 13 December 2018 after being found unresponsive following rapid tranquillisation. He had retained dangerous contraband, including controlled drugs and a bracelet concealing a blade, despite searches. Fifteen-minute observation records were falsified, and required monitoring and documentation after rapid tranquillisation were not completed; the jury found that the failure to monitor contributed to his death.

Anne Morris · Prevention of Future Deaths report View report

18 Dec 2017 Inner South London C. Williams

Anne Morris died by suicide after hanging herself while alone in a friend’s house on 26 June 2017. The principal concerns were that the Priory Hospital did not contact consented friends or relatives, did not establish a written discharge and follow-up plan, and did not liaise adequately with the relevant Oxleas Home Treatment Team before discharge. Concerns were also raised that the Oxleas team did not obtain a discharge plan or know that Anne had agreed to contact with a friend regarding community support and suicide risk.

Charlie Millers · Prevention of Future Deaths report View report

26 Apr 2024 Manchester North J. Kearsley

Charlie Millers was detained under the Mental Health Act and was found in his room with a ligature after returning from home leave; he died five days later in hospital. The report raises concerns about whether required observations were carried out and documented, and about the effectiveness and independence of investigations into such deaths. It also identifies a lack of oversight across previous concerns and investigations.

JULIA SHEEREN DELL · Prevention of Future Deaths report View report

17 Jan 2014 Cornwall A. Cox

Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

William Antony Northcott · Prevention of Future Deaths report View report

27 Jan 2025 Devon, Plymouth and Torbay L. Wiltshire

William Antony Northcott, who had treatment-resistant schizophrenia, was found deceased on 13 July 2021 after suffering a sudden fatal cardiac arrhythmia. The report raised concerns about the adequacy and consistency of information on clozapine side effects and cardiac warning signs, the detection of cardiomyopathies in patients taking clozapine, and communication between agencies and care teams.

Mr Viswambaran · Prevention of Future Deaths report View report

24 Jan 2019 Inner North London S. Bourke

Mr Viswambaran, aged 27, was found dead at home on 18 September 2018 after overdosing on co-dydramol tablets. The report raises concerns about lengthy waiting times for IAPT therapy and difficulties contacting the IAPT service, which could contribute to deterioration or disengagement from mental health support.