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Huw Irwin ERASMUS · Prevention of Future Deaths report View report

12 Dec 2024 Gwent C. Saunders

Huw Irwin Erasmus died at Aderyn Unit in Pontypool after consuming a large quantity of Yew leaves while detained under Section 3 of the Mental Health Act. Concerns were raised about the absence of documentary evidence of post-leave assessments, confusion among staff about assessment and documentation requirements, and the failure to identify and manage risks associated with ingesting Yew leaves.

Ms. Kimberley Parsons · Prevention of Future Deaths report View report

4 Mar 2014 Avon P. Harrowing

Ms. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality disorder.

Stephen Norman RICHARDSON · Prevention of Future Deaths report View report

22 Jun 2023 Liverpool and the Wirral A. Rebello

Stephen Norman Richardson died on 28 September 2019 after a self-inflicted ligature incident at the Sid Watkins Unit on 24 September 2019, following extensive brain damage and withdrawal of life support by his family. The report identified concerns including failures to secure an acute mental health bed, missed opportunities relating to treatment and risk assessment, inadequate communication and safeguarding planning, and staff not following the correct emergency response procedure. It also noted an ongoing national shortage of acute psychiatric beds.

John Atkinson · Prevention of Future Deaths report View report

29 Nov 2016 South Yorkshire (Eastern) N. Mundy

John Atkinson received psychiatric services after contacting the Mental Health Team in crisis in July 2014 and died by suicide by hanging. The report identified concerns about outdated risk assessments, failures to recognise changing presentation and risk, inadequate arrangements when staff left, poor communication, and difficulty accessing Home Treatment Team services.

William John Charles Harnell · Prevention of Future Deaths report View report

22 Sep 2015 Plymouth, Torbay and South Devon A. Cox

William John Charles Harnell suffered a fractured left hip while attempting to mobilise from his wheelchair on 22 October 2014, remained in hospital, developed hospital-acquired pneumonia and died on 15 December 2014. Concerns included delays in recognising the difficulties surrounding his discharge, assessing his mental health, approaching suitable nursing homes, and a lack of resources and guidance for managing challenging and vulnerable patients.

Moira Diane Parker · Prevention of Future Deaths report View report

30 Apr 2026 Bedfordshire and Luton B. Patel

Moira Diane Parker, a microbiologist, had experienced declining memory and cognitive function, increasing work pressure, and worsening mental health before she was found with self-inflicted stab wounds on 11 April 2025; her death was confirmed by paramedics. The report raised concerns that occupational health referral was delayed despite her raising concerns over a prolonged period, and that staff may lack sufficient knowledge and training about when such referrals can be made and what support is available.

Joanita Nalubowa · Prevention of Future Deaths report View report

13 Aug 2024 Inner North London H. Lambert

Joanita Nalubowa died after suspending herself with a ligature shortly after being told she would be discharged to Stockton, away from her family support network and against her wishes. The report raises concern that rigid accommodation criteria and the lack of discretion may create a risk of future deaths where a person's historical area of residence is inappropriate or dangerous and section 117 aftercare does not apply.

Brian Thomas RINGROSE · Prevention of Future Deaths report View report

1 Aug 2025 Milton Keynes S. Cummings

Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.

Janice Andrea Keelan · Prevention of Future Deaths report View report

19 Feb 2019 Manchester City N. Meadows

Janice Andrea Keelan, who had chronic and complex health conditions and was at risk of falling asleep or having a seizure in the bath, died by drowning on 14 November 2017. A referral for a walk-in shower was not approved until ten days after her death. Concerns included inadequate consideration of her impaired cognition and mental capacity, failure to prioritise the urgent risk, and insufficient action to involve mental health services to reduce the risk of death.

Rosalind Flett · Prevention of Future Deaths report View report

24 May 2018 South London S. Lynch

Rosalind Flett, who was detained under section 2 of the Mental Health Act and subject to enhanced observation and regular searches, used a razor blade to make a deep laceration to her neck in full view of nursing staff and died shortly thereafter. The report identified an ambiguity in search policies about whether staff could ask her to remove her bra, despite her history of concealing razor blades and previous incidents of cutting.

Mr Harold Ambrose and Mrs Wendy Ambrose · Prevention of Future Deaths report View report

25 Mar 2015 Essex E. McGann

Mr Harold Ambrose shot his wife, Mrs Wendy Ambrose, and then himself; police found both bodies. Mr Ambrose had a shotgun licence and developed worsening mixed dementia, but neither his GP nor the mental health trust referred the matter to the police firearms department. The report identified that there was no requirement for them to notify police about mental health concerns when aware that a patient held a firearms licence.

Lee Ryan Thrumble · Prevention of Future Deaths report View report

10 Sep 2021 Mid Kent and Medway S. Matthewson

Lee Ryan Thrumble was a serving prisoner who suspended himself by the neck in a cell at HMP Rochester on 17 April 2018 and died the following day. The inquest found that failures to meet his mental health needs and to respond adequately to deteriorating behaviour contributed to his death. The principal concern was that incomplete access by clinical staff to NOMIS information, linked to non-compulsory training, could prevent prisoners’ mental health needs and risks from being identified and managed appropriately.

Simon William McAndrew · Prevention of Future Deaths report View report

19 Feb 2014 South London R. Palmer

Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

Anthony Gwyn Williams · Prevention of Future Deaths report View report

2 Dec 2014 North Wales (East and Central) J. Gittins

On 9 February 2014, Anthony Gwyn Williams, whose mental health was declining, went to Pentwmpath Woods and took his own life with a ligature while his balance of mind was disturbed. Concerns included insufficient guidance on when staff could deviate from the recognised psychiatric assessment pathway, lack of continuous access to patients’ medical records, and the need for greater engagement with families and carers about care and treatment plans.

Daniela Vitalia PANI · Prevention of Future Deaths report View report

28 Mar 2024 Berkshire R. Simpson

Daniela Vitalia PANI died on 29 June 2023 after entering a train station, jumping onto the tracks and being struck by a train. Concerns were raised that potential suicide-risk mitigation measures at the station had not been implemented, and that mental-health staff lacked specific guidance and training for situations where service users declined face-to-face 72-hour reviews.

SAIFUR RAHMAN · Prevention of Future Deaths report View report

26 May 2022 Birmingham and Solihull J. Bennett

Saifur Rahman was found in cardiac arrest in his cell at HMP Birmingham on 20 January 2021, was taken to hospital after resuscitation, and died on 23 January 2021. The post-mortem recorded hypoxic/ischaemic encephalopathy associated with external neck compression, and the jury found that his intention was to commit suicide. The report raised concerns about delayed emergency calls, inadequate records of cell history, insufficient cell risk assessments, and the lack of a formal process for prison and mental health staff to inspect and act on cell risks.

BRIAN STANNARD · Prevention of Future Deaths report View report

14 Nov 2017 Norfolk J. Lake

Brian Stannard was a resident at Eversley Nursing Home and was found drowned on a beach at Great Yarmouth on 14 November 2016 after being seen asleep in his room earlier that morning. The report raised concerns about the nursing home’s capacity to manage his mental ill health and threats of self-harm or suicide, as well as incomplete staff records and limited use of the Lorenzo computer system.

Sheila Elizabeth Steggles · Prevention of Future Deaths report View report

10 Feb 2022 Norfolk Y. Blake

Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.

Kirabo Kiwanuka · Prevention of Future Deaths report View report

3 Mar 2014 Inner South London A. Harris

Kirabo Kiwanuka, a 28-year-old woman with bipolar disorder, died on 11 June 2011 after developing tachycardia, tachypnoea, pyrexia and markedly raised creatinine kinase during psychiatric treatment. The inquest recorded sudden unexpected death in a patient treated with multiple drugs, while NMS could not be confirmed or excluded as a contributory factor. Concerns included uncertainty about diagnosing and managing NMS, whether patients with physical illness in psychiatric facilities should receive medical review or be transferred, and limited family involvement in treatment decisions.

Matthew Thomas Purser · Prevention of Future Deaths report View report

30 May 2014 Swansea and Neath Port Talbot P. Rogers

Matthew Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health records.