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Frazer Charlie Williams · Prevention of Future Deaths report View report

31 May 2024 Dorset R. Griffin

Frazer Charlie Williams was found deceased on 7 March 2022 in his cell at HMP Guys Marsh, suspended by a ligature. The report identifies concerns about delays transferring prisoners requiring mental health hospital care, inadequate arrangements for managing self-neglect and healthcare handovers, shortcomings in ACCT monitoring and reviews, and other prison care and safety processes. The inquest concluded that he died by suicide in circumstances where there was inadequate assessment and monitoring of his risks of self-harm and suicide prior to his death.

Sophie Gwen Williams · Prevention of Future Deaths report View report

27 Feb 2023 North London J. Taylor

Sophie Gwen Williams died at home in the early hours of 20 May 2021 after taking a fatal overdose of prescription medications while in a psychotic or dissociative state. The report identifies concerns about the lack of assessment and management of her overdose and self-harm risk, continuity of care and crisis support, staff training and gender-affirming care, and coordination between mental health and gender-identity services.

CHRISTOPHER TOKE AJAYI · Prevention of Future Deaths report View report

31 Oct 2014 Inner South London S. Ormond-Walshe

Christopher Toke Ajayi, who had schizo-affective disorder and insulin-dependent type II diabetes, was discharged into unsupported accommodation and was found decomposed there on 17 September 2012 after apparently receiving no professional or carer visits for about a month. The report identified concerns about discharge planning, lack of supported accommodation and GP care, failures to communicate his medical needs, and failure to follow up missed appointments, medication and insulin treatment. The inquest found the cause of death to be hyperosmolar non-ketotic coma associated with diabetes mellitus, with neglect contributing.

Daniel Maurice McMahon · Prevention of Future Deaths report View report

21 Oct 2013 North London A. Walker

Daniel Maurice McMahon suffered severe head injuries after being hit by a train at Willesden Junction Station on 11 January 2012, following reports that he had fallen from a bridge and moved onto the railway track. The report raised concerns about the accuracy and completeness of information recorded by police about the location of a person trespassing on the railway, procedures for stopping trains when an unwell person is on the line, support during mental-health leave, and the use of lung-decompression needles without a valve.

Eliot HARRIS · Prevention of Future Deaths report View report

22 Aug 2022 Norfolk J. Lake

Eliot Harris, who had schizophrenia and diabetes, was admitted to Northgate under the Mental Health Act after his condition deteriorated. His food and fluid intake remained minimal, he was last seen conscious on 9 April, and he was found unresponsive and declared dead in the early hours of 10 April 2020; the inquest recorded the medical cause of death as unascertained and an open conclusion. Concerns included inadequate observations and staff training, unclear allocation of night-duty responsibilities, incomplete records and care planning, reluctance to enter his room when concerned for his welfare, and uncertainty about ensuring requested physical health checks were completed.

Ronald William MEIKLE · Prevention of Future Deaths report View report

24 Mar 2026 Milton Keynes S. Cummings

Ronald William Meikle was found unresponsive in his single-occupancy cell at HMP Woodhill on 30 April 2024 and was pronounced dead at 09:43. The report identified concerns about illicit substances, inconsistent responses to suspected intoxication, fragmented information-sharing, inadequate welfare observations, management of self-isolation and vulnerability, absence of ACCT proceedings, mental-health input, emergency response, staffing, and recurring systemic problems at the prison.

Harry Roland Ian Vass · Prevention of Future Deaths report View report

13 Jun 2024 Avon M. Voisin

Harry Roland Ian Vass attended Southmead Hospital on 26 December 2022 with agitation, paranoid thoughts and recent cocaine use, and was later admitted to the Mason Unit. He became unresponsive after vomiting, low oxygen saturations, a high temperature and discolouration of his extremities, and died after transfer back to the emergency department. Concerns included inadequate physical and non-contact observations, and a lack of awareness among mental health nursing staff that acute behavioural disturbance is a medical emergency.

Jan Michael RACIBORSKI · Prevention of Future Deaths report View report

10 Jan 2025 Berkshire R. Simpson

Jan Michael Raciborski, who had longstanding mental health issues and a brain injury, died at home on 5 February 2024 after hanging himself. The principal concern was that records of contacts with the Adult Mental Health Team contained no written risk assessments, creating risks of inadequate information sharing, misleading records, and difficulties investigating whether risks to life had been identified.

Jack Liam May · Prevention of Future Deaths report View report

1 Mar 2019 South Wales Central R. Knight

Jack May, a 20-year-old nursing student with a longstanding history of mental health problems, died in the River Taff on 25 October 2018; the inquest concluded that his death was suicide. The report raised concerns about the adequacy and accessibility of Cardiff University’s emergency, counselling, wellbeing and pastoral support services for students experiencing mental health or other personal difficulties.

Hadley John Savory · Prevention of Future Deaths report View report

11 Aug 2021 North East Kent I. Brownhill

Hadley John Savory was discharged from hospital on 25 September 2019 without evidence of a multi-agency planning meeting, and his care, support and treatment plan was unclear. His presentation later declined in the community, safeguarding referrals did not lead to multi-agency meetings, and he was found dead at home on 13 December 2019; toxicological evidence indicated that he had taken a lethal dose of methadone. The principal concerns related to hospital discharge planning, allocation of care responsibilities, meeting eligible care needs, safeguarding procedures for self-neglect or hoarding, and information sharing where mental capacity may fluctuate.

John Lowe · Prevention of Future Deaths report View report

1 Apr 2015 Nottinghamshire S. Haskey

John Lowe was an inpatient receiving mental health assessment and care after suffering a stroke. After a series of falls, his final fall on 18 February 2014 caused a fractured left neck of femur, which materially contributed to his death from bronchopneumonia on 26 February 2014. Concerns related to nursing staff beliefs that 1:1 nursing could not be provided solely for falls risk or physical care needs.

Alexander Matthew Holt · Prevention of Future Deaths report View report

3 Feb 2015 South Yorkshire (Western) C. Dorries

Alexander Matthew Holt had a history of serious self-harm attempts and died by an impulsive but deliberate act after taking an overdose that was not communicated to staff supervising his accommodation. The concerns included failure to provide intended treatment, failure of a referral process, lack of continuity and information-sharing, and insufficient consideration of risk, including that accommodation staff were unaware of his recent overdose.

Peter Patrick Adrian Barnes · Prevention of Future Deaths report View report

8 Nov 2013 West Yorkshire (West) N. Cameron

Peter Patrick Adrian Barnes died from asphyxia caused by hanging in the grounds of Cygnet Hospital, Wyke, while detained under Section 3 of the Mental Health Act 1983. Serious incidents known to nursing staff, including comments about suicide and marks on his neck, were not communicated to the Responsible Clinician, who granted unescorted leave. The report raised concerns about systems for communicating and auditing information and care decisions, involving families in care decisions, and sharing information with police when patients were absent without leave.

James Colin Day · Prevention of Future Deaths report View report

7 Feb 2024 Manchester South A. Mutch

James Colin Day, who had developed severe post-traumatic stress disorder after serving in Afghanistan, collapsed and died on Malvern Road on 6 May 2023. The report describes concerns that mental health support for service personnel with severe PTSD, both during service and after discharge, was patchy and difficult to access, and that he used alcohol and prescribed medication to cope with his symptoms.

Barry Wayne Preston · Prevention of Future Deaths report View report

4 May 2020 Manchester South A. Mutch

Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.

Jacob Michael Nicholas BILLINGTON · Prevention of Future Deaths report View report

13 Mar 2024 Birmingham and Solihull L. Hunt

Jacob Michael Nicholas Billington was unlawfully killed when he was stabbed in the neck during a night out in Birmingham on 6 September 2020. The concerns included inadequate coordination and information-sharing between agencies during the release of a high-risk prisoner with serious mental health difficulties, and a lack of clear cross-agency guidance and understanding of responsibilities.

Florence Elizabeth Catherine STEWART · Prevention of Future Deaths report View report

10 Oct 2024 Milton Keynes T. Osborne

Florence Elizabeth Catherine Stewart, who had been admitted to the Campbell Centre as a voluntary patient following detention under section 136 of the Mental Health Act, suffered a hypoxic brain injury after hanging herself and died at Milton Keynes University Hospital on 23 January 2024. The concerns identified were the failure of high-level intermittent observations to prevent her suicide and an oxygen bottle running out during resuscitation.

Linda Louise Banks · Prevention of Future Deaths report View report

19 Dec 2023 County Durham and Darlington J. Richards

Linda Louise Banks died at the University Hospital of North Durham on 10 April 2022 after taking a paracetamol overdose, against a background of alcohol misuse and deteriorating mental health. The report identified concerns about the quality of mental health assessments, triage, safety planning and record keeping, the underestimation of risk, failure to identify possible learning difficulties and provide reasonable adjustments, and delays in investigating the care provided. It also identified concerns that similar issues found in an earlier thematic review had not been effectively addressed.

Sharon Louise Kelly · Prevention of Future Deaths report View report

24 Nov 2020 Essex C. Beasley-Murray

Sharon Louise Kelly, who had a long history of mental health and alcohol problems and frequent suicide attempts, informed a family member that she would kill herself on the anniversary of her baby son’s death. On 27 June 2019, an ambulance attended her property but did not enter while awaiting delayed police attendance; when services eventually entered, Ms Kelly was deceased. The concerns included delays and communication between ambulance and police services, risk assessment and police response procedures, and arrangements for urgent mental health assessments.

Lynsey Sarah Smalley · Prevention of Future Deaths report View report

8 Sep 2023 North West Wales K. Robertson

Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.