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Khalid Abiaz · Prevention of Future Deaths report View report

20 Jun 2022 Swansea and Neath Port Talbot K. Heaven

Khalid Abiaz, a prisoner at HMP Swansea, died in the early hours of 13 September 2016 after being found suspended by a ligature. The report identified concerns that an ACCT was not opened despite suicide warning markers and relevant historical information, and that prison and bank nursing staff may not have received sufficiently frequent or up-to-date ACCT training.

Thomas Whitfield · Prevention of Future Deaths report View report

20 Apr 2017 County Durham and Darlington A. Tweddle

Thomas Whitfield was a voluntary patient at Farnham Ward, Lanchester Road Hospital, and was found hanging in his room on the morning of 28 July 2016, shortly after being re-assessed by his Consultant Psychiatrist. The concerns included whether information from his sister about perceived suicide risk was communicated and recorded, and the absence of monitoring or recording of telephone calls that might have clarified what was said.

Michael Peter McMonigle · Prevention of Future Deaths report View report

15 Aug 2016 County Durham and Darlington C. Oliver

Michael Peter McMonigle was admitted as an informal patient to Farnham Ward at Lanchester Road Hospital and was assessed as being at significant risk of self-harm. On 11 August 2015 he left the hospital during accompanied leave, was later found suspended by a ligature, and was declared dead on 12 August. The principal concerns included failures to update and communicate risk information and leave arrangements, inadequate handover and policy implementation, and delays and omissions in responding to his absence.

Lily Precious JAHANY · Prevention of Future Deaths report View report

17 May 2024 Leicester City and South Leicestershire F. Butler

Lily Precious Jahany was an 18-year-old medical student with a complex mental health history who died after taking increased doses of medication and suspending herself by a ligature in her student accommodation. The report identified concerns about the lack of first-aid training among student accommodation staff and failures to obtain and share relevant mental-health risk information, including from private clinicians.

Anugrah Abraham (“Anu”) · Prevention of Future Deaths report View report

14 Jan 2025 Manchester North J. Kearsley

Anugrah Abraham (“Anu”), a serving West Yorkshire police officer, died by hanging on 4 March 2023 after leaving home the previous afternoon; the inquest recorded a conclusion of suicide. The report identified concerns about the management of his mental health, including delayed and inadequate Occupational Health responses, unclear action when he disclosed suicidal thoughts, poor information sharing, and aspects of the PCDA and Regulation 13 processes.

John James Leo Scallan · Prevention of Future Deaths report View report

13 Nov 2017 Coventry B. Patel

John James Leo Scallan was admitted to hospital after sustaining injuries in an alleged assault and was subsequently transferred to a mental health ward as an informal patient. He was found unresponsive following a cardiac arrest, and the levels of sedative drugs in his blood after death exceeded those prescribed. Concerns were raised about the adequacy and reliability of intermittent observations, including staff understanding of the observation policy and reluctance to enter a patient's room to conduct checks.

Denise Jane PORTER · Prevention of Future Deaths report View report

21 Dec 2023 West London H. Hinton

Denise Jane PORTER died after jumping onto the tracks at Turnham Green Underground Station in front of an oncoming train on 19 February 2023. A prior similar incident had been referred to Oxleas NHS Trust, but the Trust relied on a partial summary and did not make further inquiries into the available police information. The report raised concern that this resulted in missed opportunities to recognise the level of risk and make an appropriate referral or care plan.

ELEANOR ROSE MURPHY-RICHARDS · Prevention of Future Deaths report View report

11 Jul 2021 Mid Kent and Medway S. Hayes

Ellis died on 30 September 2020 after jumping from a footbridge onto a railway track in front of an oncoming train, intending to end his life. Concerns included gaps in the safety plan, a deviation from it without an updated risk assessment, incomplete sharing of information about a recent failed hanging attempt, and advice that did not account for the risk of Ellis leaving the centre.

LEON BRIGGS · Prevention of Future Deaths report View report

4 Oct 2021 Bedfordshire and Luton E. Whitting

Leon Briggs was experiencing a psychotic disorder associated with exceptionally high amphetamine use when he was detained under section 136 of the Mental Health Act. Following restraint and conveyance to Luton Police station, he suffered cardiac arrest in the custody suite and later died in hospital. The principal concerns included poor communication, inappropriate restraint and use of force, inadequate medical assessment, unsatisfactory conveyance and supervision, and failures in risk assessment and monitoring that delayed recognition of his need for urgent medical attention.

LUKE ALF EDWARD MOULDING · Prevention of Future Deaths report View report

13 Apr 2017 Bedfordshire and Luton I. Pears

On 25 November 2016, Luke Alf Edward Moulding entered a railway line near his home after consuming alcohol and drugs, collided with a train, and died from severe traumatic injuries. The report raised concerns that an “opt in” letter following a mental-health consultation was not sent, and that the process for sending such letters could be made more effective.

Antony Declan Schofield · Prevention of Future Deaths report View report

27 Sep 2021 Manchester City N. Meadows

Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.

Margaret Walker · Prevention of Future Deaths report View report

25 Mar 2014 Manchester West J. Leeming

Margaret Walker, a detained patient at the Sephton Unit, was found unresponsive on 7 August 2012 and later diagnosed as having died from coronary artery disease. Concerns included inconsistent diabetes care, delays and omissions in obtaining and communicating medication and blood-test information, inadequate clinical-record documentation, and the defibrillator not being applied before ambulance personnel arrived.

Locket Ure Williams · Prevention of Future Deaths report View report

14 Oct 2024 Surrey R. Travers

Locket Williams, aged 15, died from injuries after leaving home and jumping to the road below on the night of 27 September 2021; their death was recognised at 00:01 on 28 September 2021. The report identified concerns about insufficient child psychiatric inpatient capacity, the recording and communication of suicide risk, and CAMHS engagement with multi-agency safeguarding meetings. The inquest found that the death was more than minimally contributed to by delays in assessment, underestimation of suicide risk, and delayed therapeutic treatment.

Sergio DUNKLEY · Prevention of Future Deaths report View report

12 May 2022 Sefton, St Helens and Knowsley J. Thompson

Sergio DUNKLEY was admitted voluntarily to a mental health ward on 24 July 2020 after threats to end his life. He was last seen alive shortly after midnight on 18 August 2020 and was found to have taken his own life before 1.30am. The report raised concerns about the lack of mandatory requirements for ligature alarms and for checking their placement in newly built mental health units, as well as failures to record observation changes and suicide-risk assessments adequately.

Paul David TEMPLETON · Prevention of Future Deaths report View report

4 May 2024 Suffolk P. Taheri

Paul David Templeton died at Ipswich Hospital on 20 April 2023 following termination of life support after asphyxiation. The Jury found that prolonged refusal to eat or drink while detained under the Mental Health Act should have been recognised as action to end his life and as elevating his suicide risk, including by other means. The report raises concern that the response from Norfolk & Suffolk NHS Foundation Trust did not adequately address these failures in suicide risk assessment.

SOLOMON JAMES BEALEY · Prevention of Future Deaths report View report

8 Oct 2015 Norfolk J. Lake

Solomon James Bealey, aged 15, was found in his bedroom on 5 February 2015 with a bag over his head and a cord around his neck, having left a note to his family. Concerns included that no action or follow-up was taken after a nurse and doctor became aware of signs of stress and a previous suicide attempt, and that the doctor did not know letters sent to Solomon’s mother had been received.

JACK OLIVER PORTLAND · Prevention of Future Deaths report View report

21 Feb 2017 Buckinghamshire C. Butler

Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

Mihangel ap Dafydd · Prevention of Future Deaths report View report

3 May 2016 Carmarthenshire and Pembrokeshire J. Layton

Mihangel ap Dafydd was detained under the Mental Health Act and placed under 15-minute observations after being assessed as at risk of self-harm. On 16 February 2014 he was found hanging from a window using a bag strap; concerns included the incorrect removal of potentially harmful property and windows that had not been adapted to prevent their use as ligature points, which the jury found contributed to his death.

Averil Hart · Prevention of Future Deaths report View report

3 Mar 2021 Cambridgeshire and Peterborough S. Horstead

Averil Hart died from anorexia nervosa on 15 December 2012, after severe weight loss and deterioration following her discharge from specialist eating-disorder treatment. The report identified concerns about inadequate monitoring and coordination of care, insufficient eating-disorder training and specialist provision, failures to provide nutritional support, delays and miscommunication in hospital care, inadequate data on eating-disorder prevalence and deaths, and the impact of the COVID-19 pandemic.

Lee Leslie Carpenter · Prevention of Future Deaths report View report

3 Mar 2020 East London N. Persaud

Lee Leslie Carpenter took his own life on 1 October 2019 after being referred by his GP to mental health services for an urgent review. Concerns included the referral being triaged as non-urgent without a documented rationale or discussion with Mr Carpenter or the GP, a lack of robust risk assessment, care planning and medication review, and the absence of a response when the Home Treatment Team visited his home on the day of his death. The report also identified no system for clearly documenting important clinical triage decisions or identifying the staff member responsible.