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Lee William Davies · Prevention of Future Deaths report View report

10 Sep 2020 Shropshire, Telford and Wrekin J. Lees

Lee William Davies, a detained patient, absconded from a mental health ward on 17 June 2019 and was found unconscious the following day after an out-of-hospital cardiac arrest. He died in hospital on 18 June 2019 after treatment was withdrawn; the inquest recorded a brain injury caused by illicit drug use. Concerns included the reduction of his observation levels despite his risk of absconding to obtain drugs, and ward-garden planting and monitoring arrangements that could allow drugs or other items to be concealed.

LISA MARIE THOMPSON · Prevention of Future Deaths report View report

10 Feb 2021 Oxfordshire S. Hayes

Lisa was found unresponsive at home on 14 March 2020 after tying a ligature around her neck, was resuscitated and taken to hospital, where she died from hypoxic brain injury following cardiorespiratory arrest caused by asphyxiation. The inquest concluded that the death was suicide. Concerns included the absence of a clear care plan after an emergency review and failures to update mental-health care plans and risk assessments with material information about her overdoses and subsequent disclosures.

Adam GALLAGHER · Prevention of Future Deaths report View report

14 Sep 2022 Newcastle and North Tyneside K. Dilks

Adam Gallagher, aged 30, died on 18 October 2021 after being found at around 9am, following communication of suicidal ideation while under the influence of alcohol. The report identifies a missed opportunity for urgent intervention, including limited assessment, no clinical input and no ambulance dispatch, and raises concerns about learning, retraining and mental-health incident protocols.

Tony Mark DUNNE · Prevention of Future Deaths report View report

20 Aug 2019 Inner North London M. Hassell

Tony Mark Dunne, who had alcohol dependence disorder, extreme anxiety and mild depression, died after jumping from a seventh-floor window on 20 February 2019. Earlier that evening, he had been found by police intending to jump and was assessed in an emergency department, but was discharged after refusing informal admission and being deemed not detainable. The principal concern was that, when he later called the Crisis Line, the call taker knew this history but did not ask whether he was feeling suicidal or arrange further hospital support.

Edward Arthur Lundy · Prevention of Future Deaths report View report

21 Mar 2018 Somerset T. Williams

Edward Arthur Lundy, who had a history of depression, was found hanging in a barn on 23 August 2016 and could not be revived. The concerns identified included a lack of continuity in his care, no psychiatric assessment despite a referral indicating this was needed, and insufficient documentation and discussion of care options and risks with his family. The report also states that evidence had not been produced showing that the proposed actions had been implemented or shared nationally.

Malcolm John TAYLOR · Prevention of Future Deaths report View report

28 Oct 2024 Norfolk J. Lake

Malcolm John TAYLOR, who had expressed self-harm and suicidal intent and was awaiting admission to a mental health hospital, probably entered the sea on 3 or 4 March 2024 and was found on Gorleston beach on 4 March 2024. He died from drowning. The report identified an insufficient number of available mental health hospital beds, with patients awaiting beds at the time of his death and the inquest.

PAUL MATTHEW GILLAM · Prevention of Future Deaths report View report

11 Feb 2019 Cornwall and Isles of Scilly G. Davies

Paul Matthew Gillam was found dead at home after consuming alcohol, drugs and six pills of unknown composition. The inquest recorded that he died on 3 June 2018 from the toxic effects of a reckless overdose of non-prescription drugs. The principal concerns related to communication and working arrangements between Addaction and the Community Mental Health Team (CMHT), including the implementation of their service-level agreement and delivery plan.

Hayley Joanne BEAVINGTON · Prevention of Future Deaths report View report

20 Feb 2025 Inner North London E. Buckett

Slightly before 1am on 21 September 2024, Hayley Joanne Beavington jumped from the fifth-floor balcony of her home and died by suicide after being discharged from hospital the previous day. The substantive concerns relate to the failure to secure a place for her at a local crisis house despite concerns about cuckooing and a view that she was definitely at risk of suicide, and the lack of instructions to challenge that decision.

Christopher James MORGAN · Prevention of Future Deaths report View report

22 Oct 2013 North and East Cambridgeshire W. Morris

Christopher Morgan, a voluntary patient at Fulbourn Hospital, died from multiple injuries after diving in front of a train at or near Ely Railway Station after leaving the hospital earlier that day. The report identified concerns about communication with family and carers before changes in risk or leave arrangements, and about staffing ratios for escorted leave from psychiatric wards.

Alison Jane DRAPER · Prevention of Future Deaths report View report

29 May 2015 Avon M. Voisin

Alison Jane Draper, who had a history of mental health problems and previous attempts to self-harm, was found ligatured in her bedroom while on 10-minute observations at Juniper Ward. She sustained an unsurvivable hypoxic brain injury and died from her injuries. Concerns included the absence of a policy for when a patient is not found during a 10-minute observation and how staff should balance hourly checks for multiple patients with 10-minute observations.

Yong Keng Hong · Prevention of Future Deaths report View report

28 Feb 2019 South London S. Hayes

Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.

Roshen Abbas Ladak-Ebrahim · Prevention of Future Deaths report View report

5 May 2013 North London A. Walker

Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.

Timothy Julian STEELE · Prevention of Future Deaths report View report

15 Mar 2021 Brighton and Hove V. Hamilton-Deeley

Timothy Julian STEELE was a 28-year-old man with a lifelong history of low mood, depression and suicidal ideation, who made multiple suicide attempts during 2020 and died at his home in Brighton on 10 August 2020. The report identified concerns that his referral was lost, that he was not followed up because of inefficient processes and failure to appoint a Lead Practitioner promptly, and that the Care Programme Approach was not followed. It also identified a fragmented approach to policies across different areas of Sussex.

Kaine Regan FLETCHER · Prevention of Future Deaths report View report

17 Jul 2025 South Yorkshire (Western) A. Pountney

Kaine Regan FLETCHER died on 3 July 2022 after deteriorating during a period of restraint following detention under section 136 of the Mental Health Act, with cocaine and other substances also identified in the stated cause of death. The report raises concern that the police and ambulance service did not share an understanding of the applicable local policy and working standards for managing section 136 incidents, creating a potential risk of preventable future deaths.

STEPHANIE DANIELS · Prevention of Future Deaths report View report

13 Dec 2013 Manchester City N. Meadows

Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

Andrew James CONNOLLY · Prevention of Future Deaths report View report

10 Jun 2025 Manchester South A. Mutch

Andrew James Connolly died after being struck by a train having entered the track at a railway station on 26 November 2024. Concerns included telephone GP appointments despite his mental health not improving, no opportunity for family input into his clinical assessment, and a lack of guidance or mechanism for these arrangements; the inquest heard that his risk was not recognised.

Ruariri Thomas STEWART · Prevention of Future Deaths report View report

10 Mar 2026 Cheshire E. Wheeler

Ruariri Thomas Stewart, aged 29, died from fatal cocaine toxicity at Weaver Lodge Independent Hospital on 31 July 2025 after a period of unescorted leave during which he probably obtained cocaine. The report identifies concerns about failures in documentation, communication, information sharing, leave decision-making, substance-misuse management, record keeping, and the quality of post-incident investigation.

Julia Ann Clarke Hayward · Prevention of Future Deaths report View report

11 Aug 2015 Surrey S. Wickens

Julia Ann Clarke Hayward died on 23 May 2014 after intentionally placing herself in the path of an oncoming train while suffering from mental illness. The inquest identified concern that care plans agreed when discharging mental health patients into the care of family members were not documented or provided to those family members, leading to uncertainty about their obligations.

Amanda Mary Spark · Prevention of Future Deaths report View report

19 Apr 2018 Dorset R. Griffin

Amanda Mary Spark, who suffered with depression, was found collapsed and unresponsive at her home on 3 September 2017 and died from an overdose of prescribed medication. The inquest concluded that her death was suicide. The principal concern was that supervision applied to her mental health medication did not also cover prescribed physical health medication, and that there was no clear policy or communication process addressing this.

Mrs Ruth Ellen Edwards · Prevention of Future Deaths report View report

18 Dec 2018 South Wales Central R. Knight

Mrs Ruth Ellen Edwards died at home on 31 August 2018 after hanging herself from an attic ladder, following a long history of mental health problems and previous suicide attempts. Concerns included her discharge after a drug overdose without psychiatric liaison assessment, inadequate risk assessment and inaccurate communication about the overdose, and potentially insufficient medication reviews despite access to many medications at home.