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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.

Dean Gary Saunders · Prevention of Future Deaths report View report

17 Feb 2017 Essex C. Beasley-Murray

Dean Gary Saunders was found unresponsive in his cell at HM Prison Chelmsford on 4 January 2016, and his death was confirmed as electrocution. The inquest identified serious failings in mental health assessment and care, the prison transfer pathway, ACCT assessments and observations, record-keeping and communication, clinical leadership, and family involvement.

Andrew Arden Nixon · Prevention of Future Deaths report View report

6 Jun 2022 Dorset R. Middleton

Andrew Arden Nixon’s mental health deteriorated from around October 2020, and after referral and assessment by mental health services he was found suspended by a ligature in wooded grounds in North Dorset on 3 March 2021. The principal concerns were that family members or carers were not fully involved in risk assessment and care planning, and that criteria for considering a Carer’s Assessment were not applied at the earliest appointment.

Jonathan Harris · Prevention of Future Deaths report View report

20 Mar 2024 Surrey A. Crawford

Jonathan Harris died in the early hours of 27 June 2022 after deliberately suspending himself while suffering a relapse of paranoid schizophrenia. The inquest concluded that his relapse followed reductions in antipsychotic medication and that an inpatient psychiatric bed was unavailable when an assessment was required. The court was concerned about the vacant consultant psychiatrist post and the shortage of inpatient psychiatric beds, which it considered presented a risk of future deaths.

Mark Ravensdale · Prevention of Future Deaths report View report

16 May 2023 South Yorkshire (Western) A. Combes

Mark Ravensdale had longstanding mental health difficulties and was found hanged, with the inquest concluding that he died by suicide. Mental health services discharged him without speaking to him directly or adequately assessing his mental health.

Shane Dean Hardy · Prevention of Future Deaths report View report

16 Jan 2017 Gloucestershire K. Skerrett

Shane Dean Hardy, a 29-year-old man with a history of substance misuse and involvement with mental health services, died after placing a belt around his neck and being found hanging from a tree on 8 March 2017. The report raised concerns that people with addiction and mental health difficulties can fall between services, and that agencies supporting an individual may not share information or identify a lead agency for communication.

Samuel Thomas Howes · Prevention of Future Deaths report View report

24 Apr 2023 South London J. Taylor

Samuel Thomas Howes died from fatal injuries after jumping in front of a train on 2 September 2020. The inquest found that his ongoing mental health issues, drug use and alcohol dependency probably contributed to his death. Substantive concerns included inadequate mental health and social care responses, failures to share risk information between agencies, inadequate custody safeguarding and failures in the missing-person investigation.

Michelle Patricia Moore · Prevention of Future Deaths report View report

26 Jun 2024 Somerset S. Marsh

Michelle Patricia Moore, who had a longstanding history of anxiety and an acute deterioration in her mental health, was found deceased at home on 31 October 2023. The inquest concluded with a short-form conclusion of suicide, with the medical cause of death recorded as compression of the neck and suspension by a ligature. The principal concerns were a lack of continuity and joined-up care between treatment for menopausal symptoms and mental health care, and an apparent absence of guidance, training and policy concerning links between menopause and mental health decline.

KEWAR GUY DOMINIC HARDING · Prevention of Future Deaths report View report

16 Aug 2013 Dorset S. Payne

Mr Harding, who had a learning disability and lived at home with his mother, deteriorated over the Easter weekend and was found critically unwell with suspected sepsis on 2 April 2013. He was admitted to hospital, transferred to Birmingham for consideration of extra-corporeal assistance and possible heart transplantation, and died on 7 April 2013; the principal concern was that an urgent mental health assessment requested on 19 March had not taken place before 2 April, potentially delaying detection and treatment of his physical decline.

Mohamed Ahmed Hany Ellaboudy · Prevention of Future Deaths report View report

30 Apr 2024 Berkshire H. Connor

Mohamed Ahmed Hany Ellaboudy, known as Moh, died after deliberately placing himself in front of a moving train; his mental state and capacity to form intention were unclear. The report raised concerns about care coordination after discharge from mental health services, reliance on telephone rather than face-to-face appointments, the regularity of multidisciplinary discussions, routes for family to report concerns, and correspondence with primary care.

William Jeffrey MASKELL · Prevention of Future Deaths report View report

14 Dec 2015 Exeter and Greater Devon E. Earland

William Jeffrey MASKELL, who had Bipolar Disorder, was found collapsed in his university room after ingesting a fatal quantity of Venlafaxine and Lamotrigine. He was taken to hospital but was declared deceased. Concerns included the lack of a clear protocol for involving relevant agencies and the Police, delays in attending and forcing entry, and a risk of future deaths from untimely intervention.

Caroline Victoria Forte · Prevention of Future Deaths report View report

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

Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.

Harry Benjamin SOUTHERN · Prevention of Future Deaths report View report

23 Jan 2025 West Sussex, Brighton and Hove G. Jones

Harry Southern had a history of mental illness, previous suicide attempt and traumatic events in the final year of his life. He died after tying a ligature around his neck with the intention of ending his life. The report raised concerns that young people and their families may not receive accessible, reliable information or timely contact with mental health and suicide-prevention services, and that funding reductions could further reduce available support.

Eleanor Valerie Fyfe BRABANT · Prevention of Future Deaths report View report

16 Nov 2018 Southampton and New Forest G. Short

On 2 November 2017, Eleanor Brabant hanged herself while alone in a room at Trinity Ward, Antelope House, Southampton. She had a history of mental illness, and her behaviour and mental state had deteriorated after her compulsory detention was rescinded without a clear care plan in place. Concerns included the application and staff training relating to patient observations, safeguarding and reporting crimes involving vulnerable patients, use of Mental Health Act powers for informal patients, and involving families in care planning when consent had been withdrawn.

Stephen LINDSAY · Prevention of Future Deaths report View report

1 Aug 2024 Cumbria R. Cohen

Stephen Lindsay, who had metastatic oesophageal cancer, pain and concerns about his mental health and suicidal ideation, died by suicide on 28 February 2024. The principal concern was that responsibility for providing his mental health treatment was passed between several teams, creating a risk that people with terminal illness may not receive mental health support during crisis.

Henry James Heselton · Prevention of Future Deaths report View report

18 May 2018 Surrey C. Topping

Henry James Heselton died by hanging in a field off Down Lane, Guildford, on 28 September 2016. The report identified concerns about unclear electronic mental health records and poor communication between mental health teams and his general practitioner, which meant relevant information was not available to inform clinical judgement.

Mary Jane BUSH · Prevention of Future Deaths report View report

20 Oct 2021 Norfolk J. Lake

Mary Jane BUSH, who had a diagnosis of anxiety disorder, post-traumatic stress syndrome and suicidal ideation, was found at her home on 6 August 2020; the inquest conclusion was suicide. The principal concerns were delays in her mental health assessment and psychological therapy, ongoing delays in providing therapy, and difficulties with recruitment and retention of suitably skilled staff.

Brandon Singh Rayat · Prevention of Future Deaths report View report

6 Sep 2017 Leicester City and South Leicestershire D. Hocking

Brandon Singh Rayat, aged 15, died in hospital on 10 August 2016 after being discovered hanging at home the previous day. The report identified a concern that there was no provision of long-term mental health care for children in Leicestershire whose anxiety prevented them from attending hospital for treatment.

Carolyne Senior · Prevention of Future Deaths report View report

11 Nov 2020 South Yorkshire (Western) S. Eccleston

Carolyne Senior died at Barnsley Hospital on 20 January 2019 after three falls while in the hospital’s care, resulting in fractures to both necks of femur. The report raised concerns that her mental health needs were not sufficiently considered in falls risk assessments and that specialist mental health support for hospital staff was inadequate.

Ms Kerry Aldridge · Prevention of Future Deaths report View report

10 Feb 2020 Inner South London A. Harris

Ms Kerry Aldridge was a student police officer who died by suicide after jumping into the path of a train at Sydenham Railway Station on 6 April 2019. The report raised concerns about the lack of established links between police Safeguarding Teams and NHS mental health teams, and about the need for further mental health training and access to non-urgent advice for officers.