Search PFD Monitor

Samuel Thomas Lindor Carroll · Prevention of Future Deaths report View report

27 Oct 2016 North Yorkshire (West) J. Heath

Samuel Thomas Lindor Carroll contacted emergency services stating that he felt suicidal and wanted to jump off a bridge, and was taken to hospital for a mental health assessment before being discharged. He was later found hanging from a tree and died from asphyxia due to hanging by ligature. The report raised concerns that police and ambulance staff did not ask whether he consented to family or friends being informed, meaning no family or friends were alerted to his hospital attendance or discharge.

Jake Harvey READ · Prevention of Future Deaths report View report

17 Jun 2026 Suffolk Nigel Parsley

Jake Harvey READ was declared deceased at home on 5 May 2025 after sustaining self-inflicted knife injuries. He had attended an emergency department two days earlier seeking mental health support but left before planned Diazepam was prescribed. The principal concerns were the absence of national guidance or timelines for administering medication during mental health agitation or crisis, and the lack of direct access to the medication for a qualified non-medical prescriber, which contributed to a delay in prescribing.

Erin Louise TILLSLEY · Prevention of Future Deaths report View report

12 Nov 2024 Suffolk D. Stewart

Erin Louise Tillsley, aged 14, died on 14 July 2023 after being found suspended by a ligature at home; emergency services were unable to resuscitate her. The inquest heard that, after she attended the emergency department following an overdose on 31 December 2022, the relevant NICE guidance and local policy on self-harm assessment and mental health support were not applied, resulting in a missed opportunity for early mental health engagement.

Paul Taylor · Prevention of Future Deaths report View report

24 Dec 2024 Nottinghamshire N. Hartley

Paul Taylor was under police investigation and, within a fortnight of learning that criminal charges had been authorised, intentionally took a large quantity of prescription medication and was found deceased at home on 3 January 2024. The report raises a concern that suspects interviewed voluntarily are not automatically referred to mental health services, with only welfare assessments by the investigating officer and no healthcare involvement.

Christopher McDonald · Prevention of Future Deaths report View report

7 Apr 2025 South London S. Reeves

Christopher McDonald, who had been detained under section 3 of the Mental Health Act and was receiving care at Bethlem Royal Hospital, died by strangulation by a ligature he had applied around his neck. Concerns included shortcomings in the individualised assessment and management of his leave after he went AWOL, failure to follow the AWOL policy, inadequate review of observation levels, and avoidable delay in identifying the ligature and communicating his relevant medical history to ambulance staff.

Jeffrey Gash · Prevention of Future Deaths report View report

18 Aug 2014 County Durham and Darlington A. Tweddle

Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

Charlotte Comer · Prevention of Future Deaths report View report

13 Mar 2023 Worcestershire D. Reid

Charlotte Comer, who had significant mental health disorders and a history of suicide attempts and self-harm, left hospital before treatment for a self-inflicted arm wound and later took a substantial overdose of Propranolol and Amlodipine. She died on 20 July 2021 despite treatment. The principal concerns were instability and excessive workloads in the care coordinator system, including a five-month period without an appointed coordinator, and the failure to prevent a senior clinician from overriding a multidisciplinary team decision about specialist treatment.

David Baddeley · Prevention of Future Deaths report View report

21 Oct 2015 Manchester South J. Kearsley

David Baddeley, who had a history of schizophrenia, died at home on 23 June 2015 after tying a ligature around his neck; the cause of death was recorded as hanging, with schizophrenia also noted. Concerns included delays and gaps in transferring and reviewing medical records, incompatibility between electronic systems, and the failure to identify his psychiatric illness and lack of antipsychotic medication during primary-care handovers and checks.

Maureen Leaver · Prevention of Future Deaths report View report

27 Jan 2014 West Sussex K. Henderson

Maureen Leaver, who had dementia and severe delusions, was admitted for assessment in July 2010 and later transferred to hospital with profound hypothermia. She died on 6 October 2010; the report identified concerns about inadequate medical supervision and systems for investigating and managing acutely ill elderly patients, as well as understanding of legal duties when changing her patient status.

Jennifer Sharren Chalkley · Prevention of Future Deaths report View report

14 Oct 2024 Surrey R. Travers

Jennifer Sharren Chalkley, aged 17, died by suicide on 12 October 2021 after being found hanging in her bedroom. The report identifies concerns about delays and misconceptions affecting Education, Health and Care Plan assessments, failures to transfer safeguarding information promptly when she changed college, and shortcomings in multi-agency assessment, information sharing and support for her mental health needs and suicide risk.

Jane Diane Livingston · Prevention of Future Deaths report View report

4 Oct 2019 Swansea and Neath Port Talbot A. Gruffydd

Jane Diane Livingston was receiving treatment for anxiety and depression and died by suicide after being found hanging in a multi-storey car park on Trawler Road, Swansea. The report identified concern that gateway assessors did not have access to her earlier review and stated concerns, potentially leading to an assessment and treatment plan based on incomplete information.

Jessica Zoe EASTLAND-SEARES · Prevention of Future Deaths report View report

10 Dec 2023 West Sussex, Brighton and Hove P. Schofield

Jessie was pronounced deceased in hospital on 17 May 2022 after being found with a ligature around their neck, having been detained under the Mental Health Act and hospitalised since 4 March 2022. The report raises concerns about inadequate community provision for autistic people, including difficulties finding suitable support and the breakdown of temporary care arrangements before Jessie’s inpatient admission.

Charlie Anthony OWEN · Prevention of Future Deaths report View report

29 Nov 2024 Berkshire R. Simpson

Charlie Anthony Owen was found deceased in his room at Combermere Barracks on 11 September 2023, after previously making and aborting two attempts to end his life in the context of relationship breakdown. The inquest identified concerns about inadequate sharing of risk-management information, insufficient consideration of welfare checks and protective factors on his return to barracks, and gaps in Army training and Vulnerability Risk Management processes.

Helena Kathleen Farrell · Prevention of Future Deaths report View report

3 Jul 2014 South and East Cumbria I. Smith

Helena Kathleen Farrell had bulimia, had been sexually assaulted, took an overdose, self-harmed, and wrote letters that appeared to be suicide letters after her death. She died from hanging following a period in which she was not seen by CAMHS until the day before her death, and those dealing with her did not recognise her suicidal feelings and intentions. The concerns included failures in the CAMHS referral and follow-up system, inadequate staffing and training, failure to recognise escalating seriousness, unrealistic demands on the school nurse, and insufficient checking of the school counsellor’s credentials.

Alexandra Jane Tolley · Prevention of Future Deaths report View report

14 Oct 2021 West Yorkshire Eastern K. McLoughlin

Alexandra Jane Tolley, aged 20, was detained in a psychiatric hospital and absconded while being escorted in the hospital grounds on 27 October 2019. She was found in cardiac arrest and died at hospital the following day. Concerns included instructions not to restrain or follow her, the informal approval of ground leave without documented criteria, and the continued use of similar absconding instructions despite an ongoing risk of further deaths.

Sofia Ann Legg · Prevention of Future Deaths report View report

4 Oct 2017 Somerset T. Williams

Sofia Ann Legg had a history of low mood and self-harm, received care from CAMHS, and was placed on a six-month waiting list for CBT. On 26 September 2016, her mother discovered her hanging at home, and the inquest concluded that her death was suicide. Concerns included access to CAMHS, delays in CBT, the lack of urgent psychiatric input, shortcomings in the recording and follow-up of a critical CAMHS meeting, and inappropriate language in the SIRI Report.

Kristian Edward Allen · Prevention of Future Deaths report View report

26 May 2026 West Sussex, Brighton and Hove G. Jones

Kristian Edward Allen, who had complex mental health issues and a history of drug and alcohol abuse, died at Millview Hospital on 16 February 2025 after taking heroin, cocaine and alcohol. The report identifies concerns about inappropriate authorisation of leave, inadequate searches and observations, poor communication, and a delayed and ineffective response to his cardiac arrest. The concerns also include staff being insufficiently trained to manage cardiac arrests and drug overdoses in acute mental health wards.

Sally Burr · Prevention of Future Deaths report View report

13 Jun 2025 West Sussex, Brighton and Hove J. Turner

Sally Burr, who had a history of mental health difficulties and repeated serious self-harm attempts, was detained under section 3 of the Mental Health Act and admitted to Meadowfield Hospital. While detained, she used internet access to research and obtain toxic plant material and needles, which she consumed on 30 May 2024 with fatal results. The principal concern was that detained adult patients’ internet access could enable them to obtain means and methods to cause serious self-harm, while staff lacked practical ways to monitor or control internet use without restricting privacy and communication.

Stanislav Mucha · Prevention of Future Deaths report View report

4 Aug 2022 Manchester North J. Kearsley

Stanislav Mucha, aged 17, died after jumping from a height at the Rock centre in Bury, sustaining catastrophic injuries. The report raised concerns about the lack of notes from an independent psychiatrist and the absence of documented agreement between professionals about the outcome of a mental health assessment and the actions required.

Katharine Emma Corrigan · Prevention of Future Deaths report View report

1 Jun 2026 Essex Sonia Hayes

Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.