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Steven Charles Costello · Prevention of Future Deaths report View report

31 Mar 2021 West Sussex C. Palmer

Steven Charles Costello attended the Princess Royal Hospital on 3 October 2019 after disclosing suicidal thoughts and having a rope at home. He remained in A&E overnight because no hospital bed was available, and was found hanging at home on 4 October after leaving the department. The substantive concerns included inadequate documentation and review of his care and condition in A&E, including the failure to update his paper notes at the required intervals.

Linsay Bushell · Prevention of Future Deaths report View report

25 Apr 2017 Liverpool and the Wirral A. Rebello

Linsay Bushell, aged 37, died on 13 October 2014 after being found having self-ligatured under her bed while detained in a psychiatric ward; the medical cause was asphyxia due to compression of the neck due to ligature strangulation. The report identified concerns including inadequate access to psychological therapies, limited understanding and documentation of self-harm, poor handover and observation records, fragmented care, delays in finding suitable placement, and insufficient staff training and support.

Neil David James McDougall · Prevention of Future Deaths report View report

10 Aug 2022 Somerset S. Marsh

Neil David James McDougall, a former serviceman with a history of mental health problems following active military service and alcohol misuse, was discovered deceased at home on 23 February 2021. The inquest concluded the death was accidental and involved toxicity. Concerns included the lack of individual post-deployment debriefing, the absence of mandatory mental health assessment during Army discharge, and the coordination of support for departing personnel.

Nadine Gillian THURMAN · Prevention of Future Deaths report View report

3 Jul 2014 Black Country R. Balmain

Mrs Nadine Gillian Thurman was found hanging at home on 5 November 2012, following recent episodes of paracetamol and vodka misuse and hospital treatment. The concerns related to psychiatric assessment, including the exclusion of a relative from contributing and the reported practice of the crisis team refusing relatives' presence.

Steven Keith Marsland · Prevention of Future Deaths report View report

13 Dec 2019 Manchester South A. Mutch

Steven Keith Marsland, who had a complex mental health background, was found suspended from a ligature on 10 June 2019; the inquest conclusion was suicide and the medical cause of death was hanging. Concerns included insufficient engagement with his family after discharge, failure to arrange a community psychiatric follow-up appointment, and limited contact with the Community Mental Health Team without escalation or discussion.

Stanislaw Wieslaw ZIELINSKI · Prevention of Future Deaths report View report

24 Aug 2021 Manchester South A. Mutch

Stanislaw Wieslaw Zielinski’s mental health deteriorated after he reported anxiety and insomnia, with care provided through telephone GP appointments and delays in mental health support. On 20 October 2020, he fell from an upstairs window and sustained multiple fractures and a subdural haematoma; he later died from a cardiac arrest due to a pulmonary embolism following hospitalisation and surgery. The concerns included difficulties communicating his deteriorating condition through telephone consultations and delays in receiving mental health support during the Covid-19 period.

Christopher Glyn Jones · Prevention of Future Deaths report View report

7 Sep 2016 North Wales (East and Central) J. Gittins

Christopher Glyn Jones died after placing himself into collision with a train while under the care of the Community Mental Health Team. The inquest identified delays in treatment plans and risk assessments, failures in providing intended treatments, and inadequate escalation of concerns during a significant decline in his mental health; it also identified possible service deficiencies in staffing cover.

Matthew George Kaliniecki WILLIAMSON · Prevention of Future Deaths report View report

15 Oct 2019 West London C. Murray

Matthew was found locked in a bathroom and had hung himself using a dressing gown cord attached to a wall-mounted radiator, resulting in his death at the scene on 24 October 2018. The report raises concerns about limited opportunities for carers and family members to provide information to mental health teams and unclear coordination between mental health providers, making access to appropriate treatment difficult.

Leanne Marie Carroll · Prevention of Future Deaths report View report

19 Mar 2025 North Wales (East and Central) K. Robertson

Leanne Marie Carroll, aged 27, died on 29 June 2024 after excessive consumption of prescribed and non-prescribed medications. She had experienced anxiety and deteriorating OCD following the birth of her first child and had been referred to mental health support, but not to the Perinatal Mental Health Service. The report raises concerns about inadequate awareness and staffing of that service and the lack of written records of Single Point of Access discussions and decisions.

Sarah Elizabeth Holmes · Prevention of Future Deaths report View report

11 Oct 2023 County Durham and Darlington J. Richards

Sarah Elizabeth Holmes, who had a history of mental health difficulties and self-harm, was found dead after discharge home following a mental health assessment; the medical cause of death was recorded as asphyxia. The principal concern was the substantial delay in the Trust’s serious incident investigation, which remained incomplete more than a year after her death and was described as neither timely nor responsive. The report also raised concern that such delays could allow lethal hazards to persist and compromise investigations intended to prevent similar deaths.

Pauline Keen · Prevention of Future Deaths report View report

12 May 2022 North East Kent J. Andrews

Pauline Keen fell at home in January 2021, sustained an acetabular fracture, and was later transferred to Harrier Lodge Care Home after hospital admission. Her mental health deteriorated, and although assessment under the Mental Health Act concluded that she should be admitted, there was a failure to ensure that the application was made without delay amid uncertainty over bed communication responsibilities. She died on 24 April 2021 from multiorgan failure, sepsis and bronchopneumonia.

Mr Twm Bryn · Prevention of Future Deaths report View report

17 Feb 2023 North West Wales S. Riley

Mr Twm Bryn died on 4 October 2021 in a shipping container near his home after suspending himself by the neck with a ligature. He had experienced mental health difficulties and was awaiting counselling after an assessment that identified a mild risk of suicide. The report raises concerns about delays and lengthy waiting lists for primary mental health support, and the lack of interim contact, monitoring or support for low-risk patients who are waiting for counselling.

Richard Walsh · Prevention of Future Deaths report View report

25 Oct 2016 Inner South London A. Harris

Richard Walsh was detained after being charged with attempted murder and, while experiencing delusions, refused food and drink with the stated intention of dying. He was transferred between HMP Highdown and HMP Belmarsh, where he was isolated in a single cell for 23½ hours a day and later died by hanging. The principal concerns were failures in communication and information-sharing between police, mental health, court and prison services, inadequate mental health assessment, and inadequate assessment of his fitness for segregation and suicide risk.

Scott James DONOGHUE · Prevention of Future Deaths report View report

28 Sep 2023 East Riding and Hull L. Harris

Scott James DONOGHUE had a history of anxiety and depression, previous suicide attempts, and was receiving support from the Home Based Treatment Team after attending the Humber Bridge intending to end his life. He died by hanging himself at home on 24 May 2022. The principal concerns were the lack of continuity among staff overseeing his care and the adequacy of the Home Based Treatment Team as an alternative to hospital admission.

Roger Adrian Stevenson · Prevention of Future Deaths report View report

13 Nov 2023 Mid Kent and Medway J. Dillon

Roger Adrian Stevenson was found deceased in supported accommodation on 2 May 2022, having last been known to be alive on 30 April 2022; the medical cause of death was fatal toxic morphine intoxication. The report identified concerns that Roger had become lost to mental health services, including a lack of follow-up, delays in care-coordinator allocation, insufficient continuity between services, and limited long-term support for cyclical mental ill health.

John Michael Kirkman · Prevention of Future Deaths report View report

8 Jul 2025 East Riding and Hull P. Marks

John Michael Kirkman, who had a long history of paranoid schizophrenia and previous detentions and admissions under the Mental Health Act, died after ingesting ████████ between 26 and 27 December 2023. The principal concern was that mental health screening information from one part of the country might not be promptly available in another because of different IT systems, potentially affecting subsequent assessments and referral prioritisation.

Charles Andrew STONLEY · Prevention of Future Deaths report View report

20 Aug 2025 Liverpool and the Wirral A. Bhardwaj

Charles Andrew Stonley, who had severe depression with psychotic features, attended hospital with suicidal ideations and psychotic and paranoid symptoms while awaiting a mental health bed. After repeatedly leaving the Emergency Department, he was found deceased hanging in a wooded area. The report raises concerns about limited legal powers and resources for managing mental health patients in Emergency Departments and shortages of mental health beds, which can leave vulnerable patients at increased risk of self-harm and death.

Rebecca Louise Overy · Prevention of Future Deaths report View report

17 Dec 2014 Nottinghamshire S. Haskey

Rebecca Louise Overy died from hypoxic brain injury caused by asphyxia while in adult secure mental health detention. Her fatal injury was self-inflicted after she was transferred from child and adolescent secure mental health detention to an adult admission ward the day after her 18th birthday, without a gradual transition plan; concerns included the immediate transfer and the lack of secure mental health care for young adults aged 18–24 with a similar clinical picture.

Alexander Charles George Tostevin · Prevention of Future Deaths report View report

6 Dec 2021 Dorset B. Allen

Corporal Alexander Charles George Tostevin died on 18 March 2018 after a significant deterioration in his mental health and while under the care of the Royal Navy Department of Community Mental Health and Welfare Team. A risk management email containing significant disclosures was not seen until the following week, resulting in a missed opportunity to reassess his risk before the weekend. The concerns included the lack of independence of the DCMH, the primacy of its view in multidisciplinary risk assessments, and the absence of a composite risk assessment and care plan.

Lewis Daryl COLGAN · Prevention of Future Deaths report View report

9 May 2018 Buckinghamshire C. Butler

Lewis Colgan died immediately at Princes Risborough Station on 15 September 2017 after jumping onto the track in front of a northbound passenger train. Concerns included the robustness of supervision of care coordinators and care teams, continuity of mental health care during staff changes and sickness, the process for overdue Care Programme Approach meetings, and the robustness of the investigation and resulting actions.