Search PFD Monitor

Todd James Salter · Prevention of Future Deaths report View report

18 May 2021 South Yorkshire (Eastern) N. Mundy

Todd James Salter was released from prison on licence in July 2019 and later experienced difficulties obtaining housing, drug support and mental health support. On 1 October 2019, he hanged himself outside Doncaster police station. The concerns included inadequate probation knowledge of available services, poor engagement and collaborative working between agencies and family, and the apparent progression toward criminal acts to obtain treatment and support.

Tomasz Nowosad · Prevention of Future Deaths report View report

20 Dec 2019 Manchester City N. Meadows

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

Sarah Louise Sutherland · Prevention of Future Deaths report View report

15 Mar 2024 Surrey K. Henderson

Sarah Louise Sutherland had significant mental health difficulties, including suicidal ideation and self-harm, and died by suicide at her home on 17 December 2022. The report identified concerns about the private psychotherapist’s lack of clinical records, assessment and review, risk assessment, therapeutic boundaries, and communication with NHS services.

Amanda Gibbens · Prevention of Future Deaths report View report

23 Feb 2022 Buckinghamshire G. Brannigan

Amanda Gibbens died on 13 July 2020 at Stoke Mandeville Hospital after suffering a cardiac arrest while detained under Section 2 of the Mental Health Act at Ruby Ward. The concerns included the use of a monitor rather than continuous direct observation during Level 3 observations and ineffective bedroom searches for prohibited items that could be used for self-harm.

Anthony John Larcher · Prevention of Future Deaths report View report

22 Oct 2021 Dorset R. Griffin

On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.

CHARLOTTE LOUISE JONES · Prevention of Future Deaths report View report

11 Mar 2026 Cumbria K. Gomersal

Charlotte Louise Jones was found deceased at her home on 10 February 2025, with her death attributed to fatal levels of alcohol and bromazolam. She had a history of self-harm and substance use, and had multiple attendances at A&E following overdose and self-harm before her death. The principal concern was that CNTW and Recovery Steps did not have an adequate procedure for exchanging information about service users, including those not accepted onto a particular treatment pathway.

Pamela Gressman · Prevention of Future Deaths report View report

1 Aug 2016 County Durham and Darlington A. Tweddle

Pamela Gressman died following the ingestion of foreign bodies, one or more of which led to a perforation of the colon; the inquest recorded hospital-acquired pneumonia as the medical cause of death. The report raised concern that insufficient consideration was given to the possible physical effects of the ingested objects and that there was no clear treatment and observation plan.

Ewan Nathanial Brown · Prevention of Future Deaths report View report

10 Nov 2020 Newcastle upon Tyne and North Tyneside C. Henley

Ewan Nathanial Brown was found dead on 30 April 2019 after absconding while awaiting mental health assessment, following concerns about his behaviour and mental health. The inquest concluded that he died by accidental drowning while experiencing an unassessed and untreated psychotic illness. Concerns included gaps in police and health-service information sharing, multiagency coordination, mental health training, and family contact during the missing-person search.

Catherine Mary MORGAN · Prevention of Future Deaths report View report

19 May 2026 Kent and Medway P. Harding

Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.

Paul John APPLEBY · Prevention of Future Deaths report View report

21 Oct 2025 Northamptonshire A. Pember

Paul Appleby was arrested for drink driving, remanded in custody, and advised to be seen by Court Liaison and Diversion before release. He was not seen by the team and was found deceased after jumping from the Grosvenor Centre on 22 February 2025; the concern was that the lack of a Saturday Court Service could give rise to future deaths.

George Edward Rogers · Prevention of Future Deaths report View report

21 Nov 2019 West Sussex J. Andrews

George Edward Rogers had a diagnosis of body dysmorphic disorder and died on 28 August 2018 after causing a fatal laceration to his chest. Following his transfer between care teams, a Lead Practitioner was not appointed promptly, resulting in a period without treatment or ongoing risk assessment. The principal concern was that such transfer arrangements could delay treatment and leave patients unmonitored.

Andrew Herrin Dodds · Prevention of Future Deaths report View report

17 Nov 2025 South Yorkshire (Western) M. Whittle

Andrew Herrin Dodds was assessed and detained under section 136 after expressing suicidal thoughts and threatening to harm himself, but was later released and allowed to board a train. He took his own life on the train and was pronounced deceased at Tamworth train station. The principal concerns were failures to pass on next-of-kin and recent section 136 information, and missing information that might have prompted further contact with mental health services.

Lily May Girton · Prevention of Future Deaths report View report

11 Aug 2022 East London N. Persaud

Lily May Girton, who had anxiety, depression and emotional dysregulation, died after taking her own life while suffering from mental illness. The inquest found that her death was contributed to by failures in the community CAMHS team concerning psychiatric assessment, risk management and titration of antidepressant medication. It also raised concerns that inadequate staffing and resources in CAMHS services pose a risk of future deaths of young people.

Michelle Susan Turner · Prevention of Future Deaths report View report

18 Nov 2020 Blackpool and the Fylde T. Holloway

Michelle Susan Turner was found unresponsive at home on 1 June 2019 and died after using heroin, cocaine and tramadol. The substantive concern was that funding for peer support workers might be lost, potentially resulting in the loss of a service described as essential for some people with mental health conditions or alcohol and substance misuse problems.

Greg HUTCHINS · Prevention of Future Deaths report View report

12 Sep 2018 Warwickshire S. McGovern

Greg HUTCHINS committed suicide on 28 August 2017 in a hotel room after suffocating himself with a plastic bag and helium. Concerns included the lack of recollection and contemporaneous or subsequent records of a telephone triage, no update in the RIO system, uncertainty about the triage’s purpose, and limited rapid information sharing for people from outside the Birmingham area.

Nuliyati BUSINJE · Prevention of Future Deaths report View report

23 Apr 2024 Cheshire V. Davies

Nuliyati Businje was an inpatient on a psychiatric unit when, after abnormal observations and worsening hyperglycaemia during her admission, she suffered a cardiac arrest. Post-mortem examination found a massive pulmonary embolus due to deep venous thrombosis. The concerns included limitations in VTE risk assessment for patients with risk factors other than reduced mobility, insufficient recognition of increased DVT risk among psychiatric inpatients, and inadequate awareness of how clot-related observations may normalise.

Johanne Blackwood · Prevention of Future Deaths report View report

27 Jul 2023 Essex S. Horstead

Johanne Blackwood, known as Jo, died by suicide on 12 June 2021 after placing herself in the path of a train. The report identified concerns about unclear Care Coordinator handovers and responsibility for oversight after discharge, the absence of an allocated Care Coordinator for several weeks, failure to update her risk assessment, care plan and security plan, and inappropriate over-reliance on family members to keep her safe.

Alan Richard Miles Davies · Prevention of Future Deaths report View report

21 Mar 2024 South Wales Central D. Regan

Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.

Christopher Paul Vickers · Prevention of Future Deaths report View report

29 Feb 2024 Gateshead and South Tyneside L. Benyounes

Christopher Paul Vickers had worsening mental health and ADHD symptoms, with escalating risks of self-harm and harm to others. He was found with a ligature around his neck on 18 July 2021 and death was certified that day. The report identified repeated missed opportunities to coordinate his care through multi-disciplinary or multi-agency meetings and to make safeguarding referrals despite the escalating risks.

Jane Marie Clark and Isobel Griffin · Prevention of Future Deaths report View report

12 Feb 2015 Northamptonshire B. Cheney

Jane Marie Clark died by suicide after leaving Berrywood Hospital on 22 August 2013 with an inadequate risk assessment, following recent suicide-related concerns and possession of a ligature. Isobel Griffin died after hanging herself on the ward on 17 August 2013, with death pronounced on 21 August 2013. The principal concerns included inadequate handover and risk assessments, failures to review relevant clinical information and treatment, and insufficient measures to minimise ligature risk.