2,023 reports
Information drawn from published reports and official responses.
Steven Roy Davidson died while in prison after a history of self-harm during a previous prison stay. The report identifies concerns that healthcare staff at HMP Chelmsford could not sufficiently navigate or search System One records, or did not sufficiently understand the importance of previous self-harm information when assessing his mental health and risk.
HCRG Care Group
Hazel Binks died on 14 January 2021 after placing a fastened plastic bag over her head, following earlier preparations to asphyxiate herself and leaving a farewell note. The principal concerns were that information about her suicidal thoughts was not passed from the GP practice administration to the GP, that the GP did not undertake a meaningful mental health or risk assessment, and that the practice’s internal review did not identify these issues.
NHS NottinghamNHS Nottingham and Nottinghamshire Clinical Commissioning GroupThe Linden Medical Group
Delina Etienne, who had schizo-affective disorder and was an inpatient receiving treatment, was found unresponsive in bed on 7 May 2021 and was declared deceased at the scene. The report identifies concerns about the chaotic response to her cardiac arrest, including failure to follow resuscitation procedures and an erroneous assumption that a DNACPR order was in place. It also identifies concerns about failures to escalate raised blood pressure and chest pain, assess VTE risk, and disclose the resuscitation error.
Department of Health and Social CareEast London NHS Foundation Trust
Ann Corfield was admitted to hospital with a urinary tract infection, low sodium levels and deteriorating mental health, later developing severe psychotic depression, poor oral intake and dehydration. She suffered a cardiac arrest and died after transfer between hospitals. Concerns included inadequate handover about anticoagulation, failure to administer prescribed prophylactic anticoagulation, poor completion of fluid balance charts, and the lack of suitably qualified staff to administer intravenous fluids at Park House.
Greater Manchester Mental Health NHS Foundation TrustPennine Acute Hospitals NHS Trust
Paula Lenihan was found deceased at her home on 6 March 2023. The medical cause of death was ischaemic and hypertensive heart disease, with combined toxicity from drugs in her system. The principal concern was that risk assessments within the Birmingham & Solihull Mental Health NHS Foundation Trust were not being completed or updated satisfactorily, creating a risk from insufficient recording of risk information.
Birmingham and Solihull Mental Health NHS Foundation Trust
David Clark was detained at Orchard Hospital under section 3 of the Mental Health Act and left on escorted leave on 26 June 2019. He was found in the Lancaster canal the following morning; the reported concerns included incomplete leave documentation, failure to follow the AWOL procedure, inadequate handover and training, and an outstanding action plan.
Lancashire & South Cumbria NHS Foundation Trust
Seth Curtis Palminder died instantly on 6 February 2022 after falling from a road bridge and being struck by southbound vehicles. The report states that he had recently been discharged from mental health care, had taken overdoses of prescribed medication, and impulsively jumped from the bridge intending to take his own life. Concerns included inadequate bridge safety measures, a lack of means to summon help or access mental health support, insufficient CCTV monitoring, and repeated previous crisis incidents and fatalities at the location.
Hampshire County CouncilNational Highways
Nicholas Alan Gray died at home on 24 July 2023 following an overdose of ████████ with the intention to end his life. Before his death, he had made attempts to harm himself and expressed suicidal intent, but was discharged without a psychiatric review or recommended mental health risk assessment. The Trust’s post-death monitoring record also contained inaccurate information and significant omissions about contacts with mental health services and known self-harm concerns.
Essex Partnership University NHS Foundation Trust
Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.
Bolton Borough CouncilNHS Bolton Clinical Commissioning GroupShannon Court Care Centre
Liam Thomas died on 28 August 2016 after being found in a shower room at Littlemore Hospital with plastic bags over his head; he was pronounced dead at hospital, and the cause of death was asphyxiation. The principal concerns were access to plastic bags and other items posing a personal risk, the effectiveness of environmental safety checks, and communication between hospital staff and Liam’s family about information and elevated risk.
Oxford Health NHS Foundation Trust
Emma Kate DORMAN died by asphyxiation by hanging on 24 February 2020 after being allowed leave from the Priestley Unit, Dewsbury & District Hospital. The leave was changed at short notice because of bed availability, and the planned visit by the Home Based Treatment Team did not take place. Concerns included non-clinical influence over the leave decision and the lack of psychologist input on the ward for more than three years.
South West Yorkshire Partnership Teaching NHS Foundation Trust
Joseph Forbes Black was found deceased at his home on 9 August 2023, having died from acute polydrug toxicity involving heroin adulterated with protonitazene and metonitazene. The report’s principal concern was that naloxone kits were not permitted to be provided by the supported accommodation provider or mental health NHS Trust to known drug users, while access was concentrated through substance misuse services with which many drug users were not engaged. The concern was considered potentially nationwide and heightened by the increased incidence of heroin adulterated with potent synthetic opioids.
Department of Health and Social CareNHS England
James Furlong, Joseph Ritchie-Bennett and David Wails were murdered by Khairi Saadallah in a premeditated attack in Forbury Gardens, Reading, on 20 June 2020. The principal concerns were failures by multiple bodies to assess and share intelligence about Saadallah’s risks, provide an adequate integrated response, and provide adequate mental healthcare in the community and prison; the report states these failures probably or possibly contributed to the three deaths.
Berkshire Healthcare NHS Foundation TrustHome OfficeMidlands Partnership University NHS Foundation TrustMinistry of JusticeNHS EnglandOxford Health NHS Foundation TrustThames Valley Police
Rebecca Begg died at Heathcotes, Moorgreen, in the early hours of 15 September 2020 after a self-harm incident, and was found unresponsive despite resuscitation. The report identified concerns about monitoring compliance with care plans, the lack of robust incident reviews, untested observation-level support plans, staff involvement in care planning, and communication and escalation arrangements with the NHS trust.
Care Quality CommissionHeathcotes Care Limited
Ann Pickering developed throat-swelling and choking complaints, was diagnosed with severe anxiety and an eating disorder, and was admitted to Kendray Hospital under a section of the Mental Health Act. She later deteriorated physically, was transferred to Barnsley Hospital, and died there on 1 July 2021. The substantive concerns included delays in recognising and inserting an NG tube, delayed acceptance of her transfer by Barnsley Hospital, and a lack of clear transfer policies and procedures for patients under a section.
Barnsley HospitalKendray Hospital
Daniel Lee, aged 22, died by hanging at a disused quarry on 16 September 2021, with the intention to end his life; the inquest concluded that his death was suicide. The report identified concerns about superficial risk assessments, the absence of a key worker, communication with the armed forces and family, and uncertainty about risk-based information sharing.
NHS South Yorkshire Integrated Care BoardSouth West Yorkshire Partnership Teaching NHS Foundation Trust
JORDAN ANTHONY BUCKTON, aged 20, was found hanging by a ligature in his cell at HMYOI Portland on 28 January 2012. Concerns included failures to share information about his previous self-harm, to follow up after antidepressant medication was prescribed, and to continue an Emotional Wellbeing course after staff absence.
Dorset Healthcare University NHS Foundation TrustHM Prison and Probation ServiceNational Offender Management Service
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
Greater Manchester Mental Health NHS Foundation TrustManchester University NHS Foundation TrustNHS Greater Manchester Integrated Care Board
Annabel Mae LEWIS, aged 15, died by asphyxia from external airway obstruction after placing a plastic bag over her head at home. The report raised concerns about CAMHS referral handling, including the lack of recorded risk assessment, follow-up arrangements, attempts to engage her parents, and proactive support after she declined an appointment because of difficulty accessing the venue.
CAMHS East – Cross Street ClinicMidlands Partnership University NHS Foundation Trust
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
Care Quality CommissionDepartment of Health and Social CareHM Prison and Probation ServiceMinistry of JusticeNHS EnglandNottinghamshire Healthcare NHS Foundation TrustPrisons and Probation OmbudsmanRanby Prison
