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Layla Stephanie Dobson · Prevention of Future Deaths report View report

16 Dec 2019 West Yorkshire Eastern J. Hobson

Layla Stephanie Dobson, a 23-year-old student with a history of mental health issues, self-harm and suicidal ideation, was found deceased at her home on 11 March 2019. The inquest recorded that she died by hanging and reached a conclusion of suicide. Concerns included the absence of a formalised process to guide practitioners on appropriate support pathways and insufficient flagging of information about current self-harm or suicide in referral decisions.

Andrew John Shambrook · Prevention of Future Deaths report View report

31 May 2023 North Wales (East and Central) J. Gittins

Andrew John Shambrook took his own life by hanging on 27 March 2022. The health board acknowledged that there was no documented or robust policy for decision-making, meeting criteria, and future treatment and care pathways when a patient was referred to the Home Treatment Team; evidence indicated that Mr Shambrook had been referred but did not meet the team’s treatment criteria.

Michael Stuart Irlam · Prevention of Future Deaths report View report

4 Sep 2013 Manchester South A. Bridgman

Michael Stuart Irlam was suffering from severe depression and anxiety and had been discharged from the CHRTT while awaiting further contact from IAPT. On 13 November 2012, he hung himself from the banister at his home. The principal concern was that vulnerable patients could experience a feeling of abandonment and deterioration while waiting without a confirmed appointment or clear information about the next stage of treatment.

Christopher Michael SEAL · Prevention of Future Deaths report View report

10 Jan 2019 Avon M. Voisin

Christopher Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff processes.

Ms Shannon Quinn · Prevention of Future Deaths report View report

6 Sep 2019 Black Country Z. Siddique

Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.

Stephen Kurt Beadman · Prevention of Future Deaths report View report

23 Jun 2023 West Yorkshire Eastern K. McLoughlin

Stephen Kurt Beadman was a 34-year-old serving prisoner at HMP Wakefield who was found unresponsive after applying a ligature to his neck and died in hospital the following day. The Inquest found that he committed suicide having been bullied by other prisoners. The principal concern was that the prison’s limited consultant psychiatrist resource was insufficient for the complex mental health needs of its prisoner population, creating concern that other deaths may occur.

Stephen Anthony WARD · Prevention of Future Deaths report View report

29 May 2014 Inner North London M. Hassell

Stephen Anthony Ward, who had a long history of depression and other mental health problems, was found hanging by a close friend on 28 February. The principal concern was that, after the crisis team contacted police to request a welfare check, nobody followed up when police did not call back within one or two hours; the police later said they could not locate his flat, by which time Mr Ward had been found hanging.

Jack Peter Zarrop · Prevention of Future Deaths report View report

2 Oct 2023 West London A. van Dellen

Jack Peter Zarrop, who had a history of mental-health difficulties, alcohol abuse and previous suicide attempts, died by suicide while in custody. The jury identified failures relating to referral to Liaison and Diversion services, opening an ACCT, access to relevant history, and removal of a bedsheet and closure of a hatch as main contributing factors. The report raised concerns about the use and training of Custodial Nurse Practitioners in police custody and the training of agency prison healthcare staff in the ACCT process.

Christopher Henrik LARSEN · Prevention of Future Deaths report View report

13 Jun 2024 Rutland and North Leicestershire I. Thistlethwaite

Christopher Henrik Larsen, a 52-year-old man, was found hanging at his home in Leicestershire on 6 January 2023 and died before a planned mental health triage call. Concerns included inadequate documentation and decision-making in multidisciplinary team meetings, inaccurate interpretation of risk information, insufficient risk assessment and discharge planning, and weaknesses in the serious incident investigation and learning process.

Felicity Jane Clough · Prevention of Future Deaths report View report

26 Nov 2021 Dorset R. Griffin

Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.

Abigail Louise SMITH · Prevention of Future Deaths report View report

27 May 2026 Essex Sonia Hayes

Abigail Louise Smith was found at Braintree Recreation Ground on 15 February 2022 after attempting to suspend herself; resuscitation was unsuccessful and she was pronounced deceased at 00:08 on 16 February 2022. The report identifies concerns about inadequate trained staffing and observation, unsuitable care arrangements, access to ligature materials, insufficient risk assessments and care plans, communication adjustments for autism and learning disability, and an unsafe discharge from hospital.

Robert John McGowan · Prevention of Future Deaths report View report

15 Jan 2025 Manchester South C. Morris

Robert John McGowan died at Stepping Hill Hospital, Stockport, on 13 August 2024 from complications arising from partially treated spontaneous bacterial endocarditis, against a background of autism and complex mental health needs. The concern was that cultural, structural and systemic barriers to accessing physical healthcare contributed to the bacterial endocarditis being only partially treated, despite advocacy, individual adjustments and a Health Passport.

Amanda Richardson · Prevention of Future Deaths report View report

9 Sep 2024 West Yorkshire Eastern K. McLoughlin

Amanda Richardson, aged 40, was transferred from prison to a low secure mental health hospital and was found dead in her bedroom on 29 April 2023. Toxicology found a very high level of a prescribed drug, which had been prescribed at double the stipulated maximum dose, alongside evidence of illicit drug use. The concerns included inadequate medication review and monitoring, failures to record and investigate searches, and the adequacy of hospital security arrangements.

Emily Katherine Inglis · Prevention of Future Deaths report View report

30 May 2019 Carmarthenshire and Pembrokeshire M. Layton

Emily Katherine Inglis was found deceased in her bedroom at Prince Philip Hospital on 22 April 2016, with a plastic bag over her head; the cause of death was given as plastic bag asphyxia. The inquest identified concerns about the absence of an overarching risk management plan and deficiencies in record-keeping, including risk management strategies and handover records.

Natasha Mary ADAMS · Prevention of Future Deaths report View report

27 Apr 2022 Birmingham and Solihull J. Bennett

Natasha Mary ADAMS died by suicide at home on 12 August 2021 after presenting to hospital with recent fleeting suicidal thoughts and being assessed as in crisis. The report identified concerns that her level of mental health care had been downgraded without clinicians following the relevant policy, and that an audit of other patients had not been undertaken four months after it was identified as an action.

MARY NABILIA GWANYAMA · Prevention of Future Deaths report View report

21 Apr 2021 Surrey C. Topping

Mary Nabila Gwanyama, who was suffering from severe depression, died on 26 May 2018 after stepping in front of an oncoming train at Weybridge Station. The principal concerns included discharge without adequate housing and risk planning, lack of formal risk assessments and medical review, ineffective medication, failures in discharge coordination, and difficulties in providing community support after she was housed out of area.

Fatemeh Afrasiabi and 70 others · Prevention of Future Deaths report View report

19 Sep 2018 Inner West London F. Wilcox

The report concerns people who died in the Grenfell Tower fire, where it was considered likely that almost all deaths resulted from smoke inhalation, although this evidence had not yet been tested in court. Concerns included the absence of a structured health-screening programme for survivors, first responders and site workers exposed to smoke, dust and potentially asbestos, together with the risk of later physical and mental health problems going unnoticed.

Stuart Michael CLARK · Prevention of Future Deaths report View report

3 Apr 2019 Exeter and Greater Devon P. Spinney

Stuart Michael CLARK died shortly after being recovered from a canal on 3 October 2017, after entering the water wearing a rucksack filled with weights. During a hospital admission before his death, he disclosed that he was a vulnerable adult and a suicide risk, but this was not escalated or followed by an assessment of his risk of self-harm or suicide. The report identified that senior clinical staff were not directly informed and that the relevant medical record entry was not available to other staff at the time.

Antony Williamson · Prevention of Future Deaths report View report

20 Dec 2024 Manchester South A. Farrow

Antony Williamson experienced chronic pelvic pain and associated mental health difficulties, including increasing suicidal thoughts, before leaving home on 19 December 2023 and entering cold water. His body was found in the River Mersey on 17 March 2024, and the inquest concluded that he died from dry drowning and took his own life while experiencing hopelessness about the investigation and treatment of his pelvic pain. The report identified a lack of liaison and communication between the medical and mental health specialties involved in his care, with no formal framework to facilitate inter-specialty communication in complex cases.

David Ayontunde Walker · Prevention of Future Deaths report View report

21 Oct 2021 East London N. Persaud

David Ayontunde Walker died on 27 November 2020 after his mental health deteriorated following discharge from hospital. The report identified concerns about repeated changes of care co-ordinator and the failure to obtain and share important risk information between the mental health trusts, resulting in an incomplete discharge risk assessment.