2,023 reports
Information drawn from published reports and official responses.
Luiz Claudio Ramos Dos Anjos died on 7 November 2019 at the railway track at St Dominic’s footbridge, Colchester, from multiple traumatic injuries following a train collision. The report raised concern that the footbridge parapet and sides provided relatively easy access to the railway track, and stated that this issue had not been remedied.
Essex County Council
On 7 May 2021, 14-year-old Robyn Lily Audrey Skilton was found in Southwater Park with a ligature around her neck, and her death was confirmed by emergency services. The inquest concluded that Robyn took her own life while struggling with her mental health, and that mental health services failed to recognise the deterioration in her mental health or provide the care and treatment she required. The report raised concerns about delayed assessment and treatment, including a lack of timely access to Child Psychiatrist and CAMHS services and insufficient resourcing.
Department of Health and Social Care
Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.
NHS EnglandNorfolk and Suffolk NHS Foundation Trust
David Nigel Phillips, who had a history of mental illness, previous suicide attempts, alcohol-related issues and type 2 diabetes, was found drowned in a rock pool near Mumbles Pier on 4 January 2015. He had been arrested the previous day after being found intoxicated in his parked car and had told police he had been attempting to take his own life. The principal concerns were that an experienced mental health professional should have assessed him and that the healthcare professional lacked access to his medical records, including mental health records, to review his medication and risks accurately.
MitieNHS WalesSouth Wales Police
Kelly Frances HEWITT, a prison officer, was found hanging at her home on 18 December 2018 and was confirmed dead by paramedics. She had been suffering from depression, which was recognised by work colleagues and prison managers. Concerns were expressed about the lack of mental health support available to prison officers, and the report states that this provision should be reviewed.
Ministry of Justice
Shaun Lea Turner was found unresponsive at home after ingesting a fatal amount of codeine. The inquest concluded that his death was suicide, with drug toxicity on a background of bronchopneumonia. His family raised concerns about delays in accessing appropriate mental health services and the effect of a missed call from those services.
Department of Health and Social Care
Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.
Birmingham and Solihull Mental Health NHS Foundation TrustBirmingham City CouncilBirmingham Women'S and Children'S NHS Foundation TrustNHS Birmingham and Solihull Integrated Care BoardNHS England
Charne Nikita Petit suffered psychotic delusions and, after a psychotic breakdown on 26 March 2023, was assessed as meeting the requirements for detention under section 2 of the Mental Health Act. No mental health hospital bed was available, and she was discharged on 31 March without assessment followed by medical treatment in a mental health hospital. She died by suicide on 12 May 2023; the narrative conclusion stated that the lack of a mental health hospital bed more than minimally contributed to her death. Concerns also included the effective detention of patients in general hospitals while awaiting mental health beds.
NHS EnglandSurrey and Borders Partnership NHS Foundation Trust
Ann Margaret SPEARING had a history of learning difficulties, bereavement and dependency issues and lived in assisted accommodation. She was reviewed by mental health, hospital and eating-disorder services but was not considered to have a qualifying mental illness, medical condition or eating disorder. She starved herself over many months and died of pneumonia and malnutrition, with self-neglect contributing in the context of bereavement, a move to a new home, anxiety and dependence issues. The principal concern was that organisational eligibility criteria excluded her from effective care, leaving her passed between agencies without positive intervention.
NHS Bristol Clinical Commissioning Group
James Kenneth Herbertson took his own life after being struck by a train near Crawley train station on 10 April 2019. Concerns included unsuitable discharge accommodation and failures to recognise and act on signs of a mental health relapse, including not referring him to the crisis team or providing additional support.
Horsham District CouncilSussex Partnership NHS Foundation Trust
Benjamin Hart, aged 25, died by hanging at his mother’s home after contacting the Crisis team three times in the preceding two days and expressing hopelessness and suicidal feelings. The report describes limited contact with the community mental health team, a breakdown in his care-coordinator relationship, and no attempted contact before his death despite the team being notified. A principal concern was severe nursing-staff shortages, which left no capacity to allocate him a replacement care coordinator.
Kent and Medway Mental Health NHS TrustNHS Kent and Medway Integrated Care Board
Leslie Andrew Swindells had a complex mental health background and, after his mental health deteriorated, was found unresponsive at home with self-inflicted puncture wounds to the neck. The concerns included assessment by a practitioner with limited mental-health training, lack of appropriate triage and escalation, failure to recognise and mitigate risk, telephone-based assessment, inadequate documentation, and unclear supervision arrangements.
Department of Health and Social Caregtd healthcare
Kelvin Igweani died from gunshot wounds after police forced entry into a flat where he had barricaded himself with a two-year-old boy during a severe mental health episode. The report identifies a concern that, despite repeated attempts by his mother to obtain help, unclear information and direction about accessing emergency mental health assessment and care meant Kelvin did not receive that support.
Central and North West London NHS Foundation TrustNHS Central East Integrated Care BoardThe Red House Surgery
Lester John STACEY, who had hypertrophic cardiomyopathy and bipolar affective disorder, was found hanging in a barn at his home on 23 October 2016 and was certified dead at the scene. Concerns included discharge from mental health inpatient care without follow-up appointments, no attempted visit to re-engage him with services, and a change in medication that does not appear to have been monitored.
Midlands Partnership University NHS Foundation Trust
Sadik Miah, who had schizophrenia and was detained in hospital, collapsed suddenly and died in Lambeth Hospital on 15 October 2011 despite resuscitation. Concerns included the monitoring of ECG abnormalities and antipsychotic-related arrhythmia risk, delays in obtaining specialist advice about hyponatraemia, and the lack of regular physician support for psychiatric in-patients with physical health problems.
South London and Maudsley NHS Foundation Trust
Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.
Department of Health and Social CareEast London NHS Foundation Trust
Trevor Anthony Evans was struggling with his mental health and had contact with police, ambulance, mental health professionals and healthcare staff before taking his own life by hanging at home on 27 February 2020. The principal concerns were over-reliance on what he told a mental health nurse, failure to review medical records and insufficient investigation of available background information, resulting in concerns that mental health risk assessments could be incomplete or inadequate.
Hywel Dda University LHB
Martin Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.
Essex Partnership University NHS Foundation TrustNHS England
Jo Anne Carol Nobbs had longstanding physical and mental health problems and was found dead at home on 2 June 2014 after disengaging from professionals and stopping collection of her medications. Concerns included failure to investigate or act on the relationship between her deteriorating physical and mental health, and the lack of a revised care plan when she stopped engaging with mental health services.
Norfolk and Suffolk NHS Foundation Trust
Trinder Kaur Birdi had a history of depression and personality disorder and was assessed as at high risk of suicide after reporting two paracetamol overdoses. Following assessment by a psychiatric nurse, the risk was reduced to low and a non-urgent Community Mental Health Team referral was made; she was later admitted with acute liver failure and died from the likely effect of self-administered drug toxicity. The principal concern was that her suicide risk was downgraded without consultation with the general practitioner, a documented second opinion, or assessment by a psychiatric doctor, and that safeguards were absent in these circumstances.
North East London NHS Foundation Trust
