2,023 reports
Information drawn from published reports and official responses.
Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.
East London NHS Foundation Trust
Darren Neil Turner was admitted to an acute psychiatric unit on 26 September 2023 after a serious mental health crisis involving suicidal behaviour, alcohol misuse and an attempted house fire. His Section 2 detention was rescinded and he was discharged on 17 October 2023; he likely took his own life by hanging the following morning and was found deceased on 20 October 2023. The report identified concerns including failures in care planning, documentation, risk assessment, care-coordinator allocation, communication with family, and discharge planning.
Essex Partnership University NHS Foundation Trust
Jaroslaw Rogala, also known as Jarek, was found deceased by hanging in his bedroom on 3 September 2016 after experiencing suicidal ideation while intoxicated with alcohol. The report raised concern that patients with addiction at risk of suicide may have no inpatient facility available for care and supervision during a crisis.
NHS South West London Integrated Care BoardSouth West London and St George'S Mental Health NHS Trust
Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.
Bedford PrisonHM Inspectorate of PrisonsHM Prison and Probation Service
Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.
Department of Health and Social CareMidlands Partnership University NHS Foundation Trust
Olayemi Oluwarotimi Kodjo Kehinde, a 34-year-old man with a history of schizophrenia illness, walked into fast-moving traffic on 26 October 2023, was struck by a van, and later died from his injuries. Concerns related to staff supervision of escorted leave and the Trust’s ability to identify incidents requiring meaningful intervention or a full governance investigation.
North East London NHS Foundation Trust
Kenneth Rippon had deteriorating mental health, including self-harm, suicidal ideation and command auditory hallucinations, and died on 5 May 2022 after jumping or falling from a viaduct at Durham Train Station. The report identified concerns about inadequate mental health assessments and risk information, insufficient family involvement in safety and discharge planning, and delays and weaknesses in the investigation of the serious incident.
Care Quality CommissionTees, Esk and Wear Valleys NHS Foundation Trust
Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.
Department of Health and Social CareNHS EnglandSouth London and Maudsley NHS Foundation Trust
Mr Keith Heatley was admitted voluntarily to hospital on 1 May 2018 and transferred to Ward 14, later leaving the family home during home leave on 18 May and being found in the water; the medical cause of death was drowning and the inquest reached an open conclusion. Concerns included the absence in Wales of a policy for reviewing and assessing voluntarily admitted patients before home leave, insufficient guidance for staff, and insufficient procedures for liaising with the family and community psychiatric nurse about preparedness and support.
Swansea Bay University Local Health Board
Amarnih Lewis-Daniel, who had experienced mental health difficulties and gender dysphoria, died after sustaining fatal injuries in a fall on 17 March 2021 while awaiting care from a Gender Identity Clinic. The report raised concerns about lengthy waiting lists, limited local support during the wait, unclear responsibility for patients’ wellbeing, limited specialist knowledge in local mental health services, and unclear guidance on prescribing bridging hormones.
NHS England
Christopher Howard Smith was a serving prisoner at HMP Lowdham Grange who died at Queen’s Medical Centre on 19 May 2019 from cardiac arrest due to a massive pulmonary embolism, predisposed by deep vein thrombosis. The report describes progressive deterioration, inadequate monitoring and clinical assessment, delayed escalation and ambulance transfer, and failures in communication and care. It also identifies concerns about unsafe clinical-care practices, inadequate record keeping and disclosure, and a lack of candour in post-death investigations.
Nottinghamshire Healthcare NHS Foundation Trust
Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.
East London NHS Foundation Trust
Juliette Kirsty SEWELL was discovered unresponsive on 16 February 2024 after being missing since 14 February, surrounded by empty medication packets, and was confirmed deceased following a fatal overdose. She had a history of mental health illness and had been awaiting a delayed follow-up appointment with the mental health team. Concerns included outstanding reviews of records for people not seen in over 12 months, ongoing clinical caseload stratification, and the lack of a scheduled review date, with a stated risk of future deaths occurring.
Birmingham and Solihull Mental Health NHS Foundation Trust
Alexander George Ball was found unresponsive at home on the night of 20 February 2014 and died following ingestion of prescription and illicit drugs. The substantive concerns were a lack of communication between the Partnership Trust and other agencies, and the absence of a dedicated Care Co-ordinator.
North Cumbria Integrated Care NHS Foundation Trust
Oliver Robinson was 34 when his body was discovered at home on 24 November 2023. The Court found that he died by self-ligature tied during acute emotional dysregulation, in the context of multiple psychosocial stressors and cannabis dependence. The principal concerns were that Cureleaf prescribed medicinal cannabis despite incomplete information, insufficient relevant psychiatric expertise and treatment options not being exhausted, failed to liaise with treating psychiatrists, and that continued prescriptions obstructed appropriate psychiatric and addictions care.
Curaleaf Clinic
Demet Akcicek was found dead in bed beside her sleeping seven-year-old son on the morning of 27 May 2022. The inquest determined that she died after taking an excess of prescribed and online-obtained medication, and that she did not intend to take her life. Concerns included a failure by a mental health service worker to arrange follow-up after a welfare call, and an insufficiently clear record of that call.
North London NHS Foundation Trust
Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.
Department of Health and Social CareGreater Manchester Mental Health NHS Foundation Trust
Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.
NHS Greater Manchester Integrated Care BoardNHS Heywood, Middleton and Rochdale Clinical Commissioning GroupPennine Care NHS Foundation Trust
Benjamin Popavach was a voluntary patient on home leave from a mental health unit, could not be contacted by medical staff, and was subsequently found in the sea off Corbyn Head, Torquay. The report identifies concerns about completing risk assessments for patients going on leave, including community risks and actions if plans break down, and sharing this learning with ward staff and community teams.
Devon Partnership NHS Trust
Cariss Lucy Stone was detained in a Psychiatric Intensive Care Unit and self-harmed on multiple occasions, including by attaching a ligature around her neck. During an interval in observations, she applied a ligature with fatal effect, and the healthcare assistant who found her did not have a ligature cutter. The concerns identified were possible inadequate understanding and training regarding observation requirements, including for agency staff, and the lack of routine access to ligature cutters for staff conducting observations.
Somerset NHS Foundation Trust
