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Laura Jane Medcalf · Prevention of Future Deaths report View report

23 Mar 2022 Manchester South A. Mutch

Laura Jane Medcalf died on 17 February 2021 after being found unresponsive in her mental health ward bed, following a period of repeated self-harm incidents and signs of deteriorating mental health. The investigation concluded that her death was suicide, contributed to by failures to recognise her deteriorating mental health and increased risk, and to take effective steps to reduce that risk. Concerns also included shortages of mental health beds and staffing challenges affecting services.

Miss Chandni Nigam · Prevention of Future Deaths report View report

11 May 2015 Berkshire P. Bedford

Miss Chandni Nigam, a 19-year-old woman with a history of depression and suicidal ideation, died after being struck by a train at Twyford Railway Station on 4 February 2014. The report raised concern that the NHS Mental Health Team did not obtain relevant history or input from her previous private clinicians when care transferred to the NHS.

Emma Louise TIMBRELL · Prevention of Future Deaths report View report

30 Nov 2016 Worcestershire G. Williams

Emma Louise TIMBRELL, who had a significant mental health history, died by hanging at her home; the inquest concluded that her death was suicide. A concern was that she might not have been able to afford the out-of-hours telephone call provided for use if her suicidal ideation increased.

Kevin Dermott · Prevention of Future Deaths report View report

13 Jun 2016 Cheshire N. Rheinberg

Kevin Dermott, who had bipolar affective disorder and was serving a prison sentence, suffered episodes of mental illness while held at several prisons and died by hanging in his cell at HMP Risley on 19 May 2014. The concerns included inadequate mental health and psychiatric care, failures in care planning and communication, and failure to follow ACCT procedures; the jury concluded that deficiencies in mental health care and observation partly contributed to his death.

David Michael Sewell · Prevention of Future Deaths report View report

7 Sep 2017 South Wales Central A. Barkley

David Michael Sewell was found in the bath at his home in the early hours of 5 June 2017 with injuries to his arms and holding a razor. He had a history of mental health difficulties, including previous self-harm and an overdose, and the inquest concluded that the cause of death was transection of the left brachial artery and recorded a conclusion of suicide. The principal concern was the apparent lack of a robust system to ensure that people with mental health problems were seen and appropriately cared for, including further efforts to re-engage Mr Sewell after he did not respond to a letter.

Michelle Louise Jennings · Prevention of Future Deaths report View report

9 Feb 2022 Manchester South A. Mutch

Michelle Louise Jennings had a history of suicidal thoughts and contact with mental health services. She died after delays in accessing therapy, prosecution following a railway incident, and problems with communication and case ownership between mental health teams. The report identified concerns about therapy waiting lists, referral and discharge arrangements, and how prosecuting authorities account for mental health vulnerability.

Stuart Michael ROBINSON · Prevention of Future Deaths report View report

16 May 2023 Liverpool and the Wirral K. Ainge

Stuart Michael Robinson, aged 20, died by suicide in prison on 25 April 2021 after a history of attempted suicide and self-harm. The inquest highlighted the need for a registered mental health nurse or other mental health expert to attend reviews for prisoners subject to ACCT procedures, particularly where there had been repeated self-harm.

Allison Vivian Jacome Aules · Prevention of Future Deaths report View report

30 Aug 2023 East London N. Persaud

Allison Aules was referred to a child and adolescent mental health service in May 2021 following concerns including self-harm, low mood and anxiety, but her referral was delayed and the eventual assessment was incomplete. She was discharged without a documented risk management plan, and was found suspended in her bedroom on 18 July 2022; the investigation states that she died on 19 July 2022 as a result of suicide, contributed to by neglect. The principal concerns were failings in care and the under-resourcing of CAMHS services, including delays in assessment and concern that continuing under-resourcing amid rising demand could result in similar deaths.

Victoria Georgia Halliday · Prevention of Future Deaths report View report

20 Oct 2016 Leicester City and South Leicestershire L. Brown

Victoria Georgia Halliday’s mental health deteriorated in 2015, with repeated crises, missing-person incidents, suspected psychotic symptoms and discharge back into the community. She was discovered to have taken her own life after a final missing-person search commenced on 29 July. Concerns included inadequate community psychiatric support, lack of local intensive psychiatric beds for female patients, failures in care planning and guideline adherence, and insufficient support networks for people diagnosed with personality disorder.

Michaela FINCH · Prevention of Future Deaths report View report

6 Feb 2026 Manchester West T. Brennand

Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.

James EMMERSON · Prevention of Future Deaths report View report

5 Jan 2022 Bedfordshire and Luton S. Cummings

James Emmerson, known as Jamie, was detained under section 136 of the Mental Health Act on 1 February 2019 but was discharged without being interviewed by an Approved Mental Health Professional. He was later detained at a police custody suite and died by hanging at home on 3 February 2019. The principal concern was confusion in the Code of Practice, which led to an interpretation that an Approved Mental Health Professional assessment was not required before discharge, exposing patients to significant risk including self-harm or suicide.

Zahra Sharif Mohamed · Prevention of Future Deaths report View report

18 Feb 2025 Inner North London S. Bourke

Zahra Sharif Mohamed, who had been detained under the Mental Health Act and sent on home leave, expressed suicidal thoughts and threatened to jump from the balcony of her fifth-floor flat. She jumped from the balcony on 12 October 2022 and died at the scene. The principal concerns were that a warrant to return her to hospital was not applied for, and that delays in obtaining and executing such warrants create a risk of patients harming themselves or others, including fatal harm.

Melanie Jane Amundsen · Prevention of Future Deaths report View report

29 May 2015 Sunderland D. Winter

Melanie Jane Amundsen, a vulnerable adult, was found dead in a bedroom on 12 September 2014 after consuming a fatal amount of alcohol. The report raised concerns about employers' and employees' awareness of mental health issues in the workplace, particularly during disciplinary processes, and about the publicity of relevant ACAS guidance.

Ronald Bainborough · Prevention of Future Deaths report View report

18 Feb 2025 Inner North London S. Bourke

Ronald Bainborough lived in supported living accommodation and had schizophrenia, substance misuse, malnutrition and a history of disengagement from mental health and primary care services. A warrant under section 135(1) of the Mental Health Act was sought after he refused assessment, but there were delays before it was granted and arrangements were made for execution; he was admitted to hospital with severe malnutrition before the warrant was executed and died from community acquired pneumonia and malnutrition. The concerns identified included the time taken to apply for and execute warrants, the absence of an official fast-track procedure, and the resulting risk of fatal harm to individuals awaiting assessment.

ROBIN ANDREW JAMES MCEWAN · Prevention of Future Deaths report View report

5 Oct 2018 North Yorkshire J. Broadbridge

On 26 January 2018, Robin Andrew James McEwan was found hanging in the basement of his home after returning from drinks with workmates. He was taken to Harrogate Hospital, where he was considered brain stem dead and died on 2 February 2018 after life support was withdrawn. The concerns included a lack of direct communication between his private therapy service and GP, limited guidance and support during delays in accessing specialist mental health services, and further possible exploration of family support.

Colette Denise Vivienne Jean DUNN · Prevention of Future Deaths report View report

1 Nov 2018 Milton Keynes T. Osborne

Colette Denise Vivienne Jean Dunn was taken to hospital by ambulance with police officers after threatening to kill herself, but was discharged without a formal Mental Health Act assessment. Later that day, she doused herself with petrol and set fire to herself, sustaining severe burns, and died the following morning. Concerns included the absence of a full mental health assessment before discharge, lack of a clear discharge protocol between relevant agencies, and inadequate facilities in Milton Keynes for people experiencing a mental health crisis.

Jude Daryl Lloyd · Prevention of Future Deaths report View report

4 Oct 2021 Manchester City N. Meadows

Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

Gary OTTWAY · Prevention of Future Deaths report View report

18 Mar 2022 Inner North London M. Hassell

Gary Ottway, aged 41, died after being found in cardiac arrest while detained alone in a seclusion room under constant nursing observation during a severe mental health episode. The report raised concerns about whether observation was constant or effective, delays in entering the room and obtaining emergency equipment, gaps in available medical training and resources, and ineffective chest compressions. The inquest determined that he died from natural causes involving two heart conditions.

Rachel Kathleen Garrett · Prevention of Future Deaths report View report

27 Jun 2023 West Sussex, Brighton and Hove P. Schofield

Rachel Kathleen Garrett had been experiencing deteriorating mental health and was found near the cliffs on several occasions. On 29 July 2020, after leaving the Royal Sussex County Hospital for a second time, she returned to the cliffs and ended her life by falling from the cliff top. The report’s principal concern was that mental health liaison staff employed by a separate mental health trust could not themselves use holding powers to prevent a patient leaving an acute hospital, creating a risk when patients with deteriorating mental health attended A&E.

Sian Leigh ARMSTRONG · Prevention of Future Deaths report View report

21 Jan 2015 Avon M. Voisin

Sian Leigh ARMSTRONG had a history of depression and had previously attempted suicide by overdose. She was assessed as needing CBT after this attempt, but had not received it by her death in June 2014. The principal concern was the delay in providing CBT, with a request for reassurance that it would be made available to children requiring it in a timely manner.