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Abdeslam BENELGHAZI · Prevention of Future Deaths report View report

10 Oct 2019 Avon M. Voisin

Abdeslam BENELGHAZI was detained under Section 2 of the Mental Health Act and was prescribed methadone alongside several other medications, including clonazepam. He died on 9 December 2017; the inquest identified concerns about inappropriate combined prescribing, inadequate monitoring and failure to escalate concerns, including after signs of over-sedation or reduced consciousness.

Charlotte Lucy Swift · Prevention of Future Deaths report View report

11 May 2021 West Sussex P. Schofield

Charlotte Lucy Swift was found unresponsive at her parents’ home on 9 April 2020 and was pronounced deceased at 19.43 hours. She had an eating disorder and urgently needed specialist inpatient treatment, but no bed became available before her death; the report also describes a national shortage of placements and an administrative error that meant she did not receive an expected update from her Consultant.

LEAH LEVINE · Prevention of Future Deaths report View report

11 Mar 2015 Manchester South J. Pollard

Leah Levine died on 5 October 2014 after getting through a window onto the roof of a house and either jumping or falling. Concerns were raised that the conditions of her temporary leave from hospital, including responsibility for supervision and any observation regime, had not been clearly agreed, documented, or consistently understood by staff.

Sarah Anne Shepherd · Prevention of Future Deaths report View report

16 Dec 2013 Surrey A. Hewitt

Sarah Anne Shepherd, a patient detained under the Mental Health Act, was found in her room with a plastic bin liner over her head on 12 September 2011 and died in hospital the following day. The report identified concerns about unclear referral processes to the Psychiatric Intensive Care Unit, failures to attempt resuscitation in accordance with guidance, and uncertainty and misleading materials concerning resuscitation training.

Michael Raymond SMITH · Prevention of Future Deaths report View report

10 Nov 2022 County Durham and Darlington C. Oliver

Michael Raymond SMITH entered HMP Durham on 10 July 2020, was transferred to SACU after being found to have packages concealed internally, and was discovered self-suspended on 11 July; he died in hospital on 13 July 2020. The principal concerns included the absence of medical and mental health assessments, inadequate staffing while he was subject to three-man unlock, delays in responding to the suspension, and weaknesses in SACU record keeping and multidisciplinary oversight.

George Allan Taylor · Prevention of Future Deaths report View report

6 Feb 2015 Cornwall A. Cox

George Allan Taylor, who had a history of mental health issues and previous overdoses, was found hanged at home on 2 July 2013 after leaving a care home and returning home under daily supervision. The report identified concerns about inadequate provision of acute psychiatric beds in Cornwall, with 8 to 12 patients per month typically sent out of county, and noted that a future death could result from this lack of beds in changed circumstances.

Jaden Matthew FRANCOIS-ESPRIT · Prevention of Future Deaths report View report

22 Feb 2021 Inner North London M. Hassell

Jaden hanged himself at home on either 25 or 26 August 2020, after becoming increasingly withdrawn and feeling isolated. The principal concern was that his deteriorating mental wellbeing was not recognised by colleagues, so he was not offered psychological counselling or other support. Other concerns included difficulties related to dyslexia, workplace treatment, and the need for a fuller understanding of station culture and Jaden’s experiences.

Charlotte Grace · Prevention of Future Deaths report View report

29 Oct 2019 Cumbria N. Shaw

Charlotte Grace was discharged from hospital on 20 September 2018 and was found hanging the following evening; the inquest recorded that she took her life by hanging on 21 September 2018. The principal concern was that the Home Treatment Team and her nominated next of kin were not invited to the discharge meeting, despite her being at chronic high risk of suicide and being referred for follow-up care.

Simon Peter REYNOLDS · Prevention of Future Deaths report View report

24 Jul 2015 Avon M. Voisin

Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of risk.

Martin Glyn Baker · Prevention of Future Deaths report View report

3 May 2018 Plymouth, Torbay and South Devon A. Cox

Martin Glyn Baker, who had longstanding mental health difficulties and a history of suicide attempts, died following a prescription drug-related death. The inquest identified concerns about inadequate communication with his family, a shortage of care coordinators, and a risk assessment that did not address his periodic impulsivity.

Rebecca Jay ROMERO · Prevention of Future Deaths report View report

13 Dec 2017 Avon M. Voisin

Rebecca Romero died at home on 19 July 2017 after being found with a ligature around her neck, five days after discharge from a psychiatric unit and while under community team care. The report raised concerns about gaps in post-discharge contact and medical review, unclear and inconsistent care planning and risk terminology, communication by text, and arrangements for transferring children between out-of-area and local psychiatric services.

Mohammed Zeeshan Akram (Zee) · Prevention of Future Deaths report View report

27 Nov 2023 Inner North London M. Lee

Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.

Yasmin Louise ADAMS · Prevention of Future Deaths report View report

20 Jun 2024 Derby and Derbyshire P. Nieto

Yasmin Louise ADAMS, who had emotionally unstable personality disorder and a history of self-harm, was found suspended and unconscious in her prison cell on 12 November 2016 and died in hospital the next day. Concerns included a 29-minute gap in observation checks, fixed shower rails presenting ligature risks, uncertainty about staff training on personality disorder and learning disability, and the use of cellular confinement for a prisoner on an ACCT.

Daniel Clements · Prevention of Future Deaths report View report

13 Jul 2022 West Yorkshire Eastern K. McLoughlin

Daniel Clements, aged 27, was taken to hospital by police for a psychiatric assessment on 19 July 2021 and was discharged to his GP after being deemed not to have a mental illness. Later that evening, he ran into the path of a fast-moving train and sustained fatal injuries. The principal concerns were how to keep people displaying suicidal ideation safe when they are not considered mentally ill, and whether agencies adequately supported Mr Clements, who was described as vulnerable and had experienced homelessness and difficulties accessing support and medication.

William Philip Hafele · Prevention of Future Deaths report View report

24 Nov 2014 Surrey M. Fleming

William Philip Hafele, who had a history of mental ill health and alcohol dependence, was admitted to hospital after being found intoxicated and wanting to take his own life. After leaving the ward and being redesignated by police from missing to absent, no immediate enquiries were made; he was later found dead in a hotel room after suffocating using helium gas. The principal concerns related to inadequate training, risk assessment, communication, and understanding of responsibilities between the police and hospital staff.

Mark Patrick DANIELS · Prevention of Future Deaths report View report

1 Jun 2015 Inner North London M. Hassell

Mark Patrick Daniels hanged himself following several contacts with South Camden Crisis Response and Resolution Team. The principal concerns were failures to carry out and record planned visits, communicate within the team and with crisis houses, progress a crisis-house referral promptly, and consider hospital admission despite identified suicide risk and Mr Daniels stating that he did not feel safe at home.

FRED MALCOLM REYNOLDS (Ted) · Prevention of Future Deaths report View report

15 Jul 2021 Mid Kent and Medway S. Hayes

Ted died in hospital on 30 October 2019 from an acute on chronic subdural haematoma following a head injury. He had experienced falls, increasing frailty, low sodium and anaemia, and the inquest concluded that the combination of these factors contributed to his death. Neurological observations advised after the head injury were started but not continued, and the reason was not documented in the medical records.

Corin Bonaparte · Prevention of Future Deaths report View report

7 May 2021 Exeter and Greater Devon N. Rheinberg

Corin Bonaparte, a young man aged 23, was found hanging in his cell at HMP Dartmoor on 28 February 2017 after his former partner ended contact with him during a telephone call. Resuscitation efforts were unsuccessful. Concerns included the failure to open an ACCT after he disclosed deliberate self-harm, suggesting inadequate training, and an eight-minute delay in an ambulance leaving the prison because an escort was being sought.

Kashim ALI · Prevention of Future Deaths report View report

28 Oct 2024 Inner North London I. Potter

Kashim Ali was detained under section 3 of the Mental Health Act 1983 at Mile End Hospital and died on 21 May 2024 after being found unresponsive in bed; attempts at resuscitation were unsuccessful. The concerns identified included failures to escalate NEWS2 scores, shortcomings in one-to-one observation practices, and inaccurate observation records, which were considered to create risks to patient safety and future patients.

Thomas Wedrychowski · Prevention of Future Deaths report View report

28 Nov 2019 Wiltshire and Swindon N. Rheinberg

Thomas Wedrychowski had paranoid schizophrenia and had been prescribed antipsychotic medication for a number of years. Expert evidence indicated that the medication caused diabetes and contributed to morbid obesity; the medical cause of death was recorded as diabetic ketoacidosis and medication-induced diabetes mellitus. Concerns included whether higher-risk patients should receive more frequent diabetes monitoring and whether physical healthcare findings were adequately shared between primary and secondary care providers.