Search PFD Monitor

Barry HARMER · Prevention of Future Deaths report View report

12 Feb 2026 Buckinghamshire C. Butler

Barry Harmer was found deceased at home on 11 April 2024 after sustaining a neck injury he had likely inflicted upon himself. He had been known to community mental health services, had agreed to voluntary psychiatric admission, and was awaiting a bed while remaining at home. Concerns included inadequate pursuit and communication regarding bed availability and home safety responsibilities, the absence of an earlier face-to-face psychiatric review, and shortcomings in the robustness and timely review of the investigation and learning process.

Ollie Lee · Prevention of Future Deaths report View report

8 May 2026 South Yorkshire (Western) H. Berry

Ollie Lee, who had a history of suicidal thoughts and self-harm, died by suicide on 6 October 2024. The principal concerns were poor communication and engagement between the agencies involved, including failures to share information about self-harm and CAMHS discharge, which resulted in missed opportunities for continued mental health support. Important discussions about Ollie’s preferred name and pronouns were also not recorded or acted upon.

Peter Alfred Kelly · Prevention of Future Deaths report View report

15 Dec 2023 South Yorkshire (Eastern) N. Mundy

Peter Alfred Kelly was released from police custody on the morning of 26 April 2023 and was found hanged at 07:45 the following day, believed to have been dead for some time. The concerns included failures to complete the pre-release risk assessment properly, understand processes for involving the Liaison and Diversion team, and recognise potential mental health vulnerabilities at release.

Anthony John Preston · Prevention of Future Deaths report View report

11 Aug 2016 Rutland and North Leicestershire R. Chapman

Anthony John Preston was admitted to The Priory Hospital in October 2013, discharged home on 11 November 2013, and was admitted to The Bradgate Unit four days later after becoming extremely anxious and depressed. He hanged himself in May 2014. Concerns included the lack of robust documentary evidence that his discharge had been communicated to the Leicestershire Crisis Team, the absence of immediate follow-up, and the resulting lack of support for him and his main carer when he was considered at high risk; the report states that no causal connection was suggested between his death and the discharge arrangements.

Emily VOUKELATOU · Prevention of Future Deaths report View report

1 Nov 2016 Inner North London M. Hassell

Emily Voukelatou left North Camden Crisis House after writing notes of intent, travelled to Beachy Head on 30 June 2016, and jumped from the cliff. Concerns included the lack of routine involvement of family members in care and Crisis House’s failure to return her sister’s repeated calls before and after her death.

Angela Catherine Brealey · Prevention of Future Deaths report View report

24 Dec 2015 Staffordshire South A. Haigh

Angela Brealey was found dead at home on 19 September 2014 after hanging herself. She was receiving treatment from local secondary psychiatric services, but no full assessment by a Consultant Psychiatrist had been carried out. Concerns included the handling and confidentiality of information from third parties, limited multidisciplinary team involvement, and whether pressure on serious incident reviewers reduced the effectiveness of the review.

Vivian Herbert HUNT · Prevention of Future Deaths report View report

6 Aug 2014 Powys, Bridgend and Glamorgan Valleys A. Barkley

Vivian Herbert HUNT, an 84-year-old patient on the Mental Health ward, fell in his hospital room on 3 April 2014 after a similar fall the previous day, sustained a facial injury, deteriorated, and later died from a brain bleed. The report raised concern that no neurological observations were made during specified periods after the falls and facial injury.

Sophie Jayne Wilson · Prevention of Future Deaths report View report

2 Aug 2024 County Durham and Darlington J. Richards

Sophie Jayne Wilson was found deceased at home on 2 July 2023 following an overdose, after she had disclosed the overdose to the Crisis team and declined assistance from ambulance responders. The principal concerns were that responders were unaware of her multi-agency familiar face plan and that crucial information about capacity, risk and how to support her was not readily accessible to them.

Emanuel Kolade LADAPO · Prevention of Future Deaths report View report

23 Apr 2024 Inner North London M. Hassell

Emanuel Kolade Ladapo had paranoid schizophrenia and depression and was receiving treatment from Camden & Islington services. He died by suicide, with the medical cause recorded as asphyxiation via a plastic bag and inhalation of nitrogen gas. Concerns included a lack of engagement with his sister, and failures to ask about suicidal feelings when he had deteriorated and remained depressed, including a failure of the initial management review to identify the omission.

Rachal Marie Murphy · Prevention of Future Deaths report View report

8 Dec 2016 Manchester South J. Kearsley

Rachal Marie Murphy died at home on 8 September 2015 after taking medication prescribed to other family members; the medical cause of death was recorded as acute hypoxia due to morphine overdose, and the conclusion was that she had taken her own life. The report identified concerns about fragmented inter-agency care, failures and delays in referrals and investigations, overlooked CAF documentation, and delays in Early Help case allocation.

Robert Maxwell SMITH · Prevention of Future Deaths report View report

21 May 2025 South Wales Central A. Morse

Robert Maxwell Smith died by hanging on 26 October 2023, and the inquest concluded that his death was suicide. Concerns were raised that mental health services’ guidance and patient information about sharing and gathering information from family members lacked clarity and sufficient detail.

James Fitzpatrick · Prevention of Future Deaths report View report

12 Feb 2026 Dorset R. Griffin

James Fitzpatrick, an 89-year-old man with decompensated heart failure and respiratory illness, became unresponsive after coughing and was found with food material in his mouth; his death was confirmed on 14 February 2024. The principal concerns were the lack of written national and local guidance for care handovers, and the risk that incomplete or incorrect handover information could affect patient care and contribute to a future death.

Rastislav Petrisko · Prevention of Future Deaths report View report

6 Mar 2018 Inner South London A. Harris

Rastislav Petrisko, who had a history of suicide attempts, drug and alcohol misuse, and mental health admissions, took a fatal overdose after being granted unescorted leave from a mental health ward. The concerns included an apparently unsuitable low-risk assessment, inappropriate unescorted leave, delayed notification of police when he failed to return, and differing approaches to risk assessment.

Andrew Ralph Mitchell Farrow · Prevention of Future Deaths report View report

20 Apr 2015 Wiltshire and Swindon P. Hatvany

Andrew Ralph Mitchell Farrow died at home on 7 July 2014 as a result of self-administered acute codeine and alcohol toxicity. He had expressed a wish to be admitted to hospital for his own safety, and the concern was that no beds would have been available at Green Lane Hospital Devizes if admission had been needed.

Stephanie Moyce · Prevention of Future Deaths report View report

25 Feb 2022 Essex S. Horstead

Stephanie Moyce, who had a history of mental health issues and repeated suicide attempts, took her own life on 30 July 2021 and was discovered by her partner. The report identified concerns about unclear responsibility for care and oversight after psychotherapy discharge, inadequate discharge planning and safety-netting, the lack of routine multidisciplinary discussion, and insufficient involvement of her carer in Section 117 after-care reviews.

Amanda Jane Vickers · Prevention of Future Deaths report View report

3 Feb 2014 North and West Cumbria D. Roberts

Amanda Jane Vickers had a long history of depression and suicidal ideation and was found hanging at her home on 22 August 2013. She was awaiting admission to 81 Lowther Street Crisis Home, but no place was immediately available; the report raised concern that this six-bedded unit was the only facility of its type in the county and suggested reviewing the availability of beds.

Narjit Gill · Prevention of Future Deaths report View report

9 Feb 2024 Coventry and Warwickshire D. Lakin

Narjit Gill died by hanging on 5 May 2023 after recently receiving mental health support and continuing to express suicidal thoughts. The principal concern was the failure to remove an unspecified item seen during a home visit on 3 May 2023, in light of his continued suicidal ideation.

Richard Andrew Collins · Prevention of Future Deaths report View report

7 Mar 2024 Dorset R. Griffin

Richard Andrew Collins, who had bipolar affective disorder, was struck by an articulated lorry after walking into the eastbound carriageway of the A421 on 9 February 2022, and his death was confirmed despite resuscitation attempts. The report raises concerns that, after his mental health deterioration and hospital admission, his driving fitness and duty to notify the DVLA were not revisited by medical professionals, and that similar missed opportunities may occur nationally.

Adam James Withers · Prevention of Future Deaths report View report

15 Feb 2016 Surrey A. Hewitt

Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

Songul BOZDAG · Prevention of Future Deaths report View report

26 Jul 2017 Inner North London M. Hassell

Songul Bozdag, who had schizophrenia and other mental health conditions, died after jumping from a tenth-floor window on 9 February 2017. Concerns included missed mandatory reviews, incomplete recording of consultations, failure to record a required care plan approach, an incorrect drug card that left her under-medicated, and the absence of a system safety net to identify these errors.