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Pamela Margaret Bailey · Prevention of Future Deaths report View report

27 Jan 2014 South Yorkshire (Western) D. Coutts-Wood

Pamela Margaret Bailey left Hawthorn Ward, Northern General Hospital, on 23 March 2013 and was later found deceased at a secluded location near Ladybower, Derbyshire, on 29 March 2013. The medical cause of death was hypothermia. The substantive concerns included ward door security, staffing levels, and the absence of a photograph available to police when she disappeared.

Mr Stuart Tokam · Prevention of Future Deaths report View report

13 Aug 2021 East London G. Irvine

Mr Stuart Tokam, who had a documented history of depressive illness and two previous attempts to take his own life, died after hanging himself from railings at Dalaman Airport, Turkey, on 18 September 2020. Concerns included an unacceptable delay in arranging a clinical assessment and the apparent absence of a process to triage referral acuity and expedite assessment where necessary.

Carol Ann Robinson · Prevention of Future Deaths report View report

30 Mar 2023 East London N. Persaud

Carol Ann Robinson died at Queen's Hospital on 8 May 2022 after taking an overdose of medication and being diagnosed with mixed drug toxicity. The principal concerns were that she was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multidisciplinary discussion, or communication with her domiciliary care agency and family about the withdrawal of support.

Shannon Kimberley Gee · Prevention of Future Deaths report View report

3 Feb 2015 Cornwall A. Cox

Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and records.

MORGAN-ROSE HART · Prevention of Future Deaths report View report

19 Dec 2023 Essex S. Hayes

Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.

Scott Alan Taylor · Prevention of Future Deaths report View report

6 Jul 2026 Gateshead and South Tyneside J. Thompson

Scott Alan Taylor, who had treatment-resistant obsessive compulsive disorder and was receiving community treatment, died by suicide on 12 May 2023. The report raises concerns about the limited number, geographical concentration, access criteria and capacity of tertiary services for patients with treatment-resistant OCD, including a reported waiting list of over 12–15 months.

Chentoоri Chanthirakumar · Prevention of Future Deaths report View report

5 Feb 2016 Inner North London M. Hassell

Chentoоri Chanthirakumar, a 24-year-old medical student, died by suicide after being discharged from a period of inpatient mental health treatment. The concerns included the university communicating by email about her examinations rather than arranging a personal meeting, and mental health staff not fully absorbing concerns raised by others because of confidentiality concerns.

SAMANTHA JANE GOULD and CHRISTINE ELIZABETH GOULD · Prevention of Future Deaths report View report

28 May 2021 Cambridgeshire and Peterborough N. QC

Sam died by suicide from an overdose of prescribed medication on 2 September 2018, aged 16. Chris died by suicide after deliberately stepping in front of a passing train on 26 January 2019, aged 17. The principal concerns included insufficient overnight support for adolescents cared for at home, shortcomings in local authority support and coordination, reluctance to use a Borderline Personality Disorder diagnosis, and unclear and inadequately implemented procedures for patients absent without leave.

James Oliver Sheppard · Prevention of Future Deaths report View report

8 May 2025 Gloucestershire R. Wooderson

James Oliver Sheppard, who had a history of mental health difficulties, died after diving onto the track in front of a train on 27 June 2023. The principal concern was that there appeared to be insufficient beds available in psychiatric units to meet patient demand.

Lynsey Ellen Dearden · Prevention of Future Deaths report View report

18 Nov 2025 Staffordshire and Stoke-on-Trent E. Serrano

Mrs Lynsey Ellen Dearden was found deceased at her home on 11 March 2025. The inquest concluded with a short-form conclusion of suicide; the stated cause of death was asphyxiation, with anxiety and depression recorded in Part II. Concerns included failures to provide allocated Community Psychiatric Nurse appointments and to complete a standard assessment framework, alongside the absence of policies or guidance governing these processes.

Luke Mervyn WHITELAW · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London I. Potter

Luke Mervyn Whitelaw, who was known to mental health services, died by suicide; his body was recovered from the River Thames on 17 March 2023. Before his death, his mental health deteriorated and a referral for urgent psychiatric review following his disclosure that he would accept informal hospital admission was not acted on. Concerns included insufficient consideration of historic and current risks, inadequate documentation and exploration of deterioration, and a lack of reassurance that identified learning points would be addressed.

Grazyna WALCZAK · Prevention of Future Deaths report View report

4 Mar 2021 Inner North London M. Hassell

Grazyna Walczak died after jumping three storeys from her flat on 25 or 26 September 2020 while suffering an acute depressive illness. Before her death, she was assessed as being at low to moderate risk, but was not asked whether her family could be notified. The report also raised concern that a required 72-hour investigation report was completed about five months after her death.

Deborah Margaret LAMONT · Prevention of Future Deaths report View report

20 Jan 2020 South Wales Central G. Hughes

Deborah Margaret Lamont travelled to a hotel on 28 March 2019, where she suspended herself by a ligature and was found deceased by police officers shortly after 11pm. The principal concern was that police officers might incorrectly conclude that the power under section 136 of the Mental Health Act did not apply in a hotel room, potentially placing an individual at risk of death.

Daniel-John VARNDELL · Prevention of Future Deaths report View report

29 Nov 2022 Hampshire, Portsmouth and Southampton R. Rhodes-Kemp

Daniel-John Varndell, who was considered at high risk of serious harm and had mental health and drug-use concerns, was released on licence to an approved premise in May 2020. After a licence condition concerning appointments with mental health practitioners was removed without discussion with MAPPA professionals or a mental health practitioner, he absconded following an altercation and was later the subject of an investigation into his death. The report raises concern that unilateral removal of licence conditions could contribute to a future death.

Kirandip Bharaj · Prevention of Future Deaths report View report

9 Oct 2023 Blackpool and the Fylde A. Anthony

Kirandip Bharaj died aged 45 on 14 September 2019 after sustaining burns and inhaling fumes in an accidental fire at her flat. She had a known eating disorder, declining weight and increasing confusion before her death. The principal concern was that adult social care staff may not recognise deterioration in eating disorders without appropriate tools, training and access to relevant guidance, potentially leaving people without urgent medical assessment and treatment.

Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report View report

16 Apr 2015 Manchester South J. Kearsley

Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police custody.

Mr Colin Johns · Prevention of Future Deaths report View report

18 Apr 2018 Black Country Z. Siddique

Mr Colin Johns, a 71-year-old man with a history of low mood, alcohol dependency and previous self-harm, was discharged home after presenting with suicidal thoughts and requesting psychiatric admission. He subsequently took an overdose of co-codamol and died after being found collapsed at home. Concerns included inadequate communication and history-taking about self-harm attempts and insufficient efforts to find a suitable inpatient bed.

Christina O'Brien · Prevention of Future Deaths report View report

14 Jun 2016 Inner South London C. Williams

Christina O'Brien died by suicide on 17 September 2015 after hanging herself outside her flat; she also had injuries to her arms and legs. She had a long-term mental illness and was receiving treatment and care from SLAM. The principal concern was that community respite options for people experiencing mental health crises were limited, particularly after the withdrawal of Dove House, a non-hospital respite facility that had previously benefited her.

Jason Basalat · Prevention of Future Deaths report View report

27 Nov 2017 Milton Keynes T. Osborne

Jason Basalat was arrested after grabbing the steering wheel of a bus, causing it to crash into road barriers, and was remanded to HMP Woodhill. He was found hanging in his cell the following day and later pronounced dead at hospital. Concerns included inadequate sharing of information about his behaviour and mental state with the prison, and the lack of a mental health assessment or appropriate placement consideration before his transfer.

Mina TOPLEY-BIRD · Prevention of Future Deaths report View report

9 Apr 2021 County Durham and Darlington J. Thompson

Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.