Search PFD Monitor

Heather Birchall · Prevention of Future Deaths report View report

28 Jun 2019 Wiltshire and Swindon D. Ridley

Heather Birchall, who was homeless and had mental health problems and alcohol dependence, died after consuming excess amounts of medication alongside alcohol; bronchopneumonia also contributed to the mechanism of death. The principal concern was that healthcare professionals assessing people in police custody might lack relevant mental health information because of confidentiality barriers, potentially limiting informed decisions about further care and safeguarding life.

Melanie Ruth Pinnell · Prevention of Future Deaths report View report

26 Mar 2026 Suffolk D. Sharpstone

Melanie Ruth Pinnell had a history of depression and recently described suicidal thoughts and ideation. No follow-up was arranged by the GP practice after February 2025, and a psychiatrist’s recommendation to start Sertraline was not actioned. Melanie was found hanging at home on 4 May 2025. The report identified these matters as significant risks to patient safety.

William Stanley Higgleton · Prevention of Future Deaths report View report

9 Mar 2016 East London N. Persaud

William Stanley Higgleton, who had anti-social personality disorder and mixed anxiety and depressive disorder and was considered at high risk of harm to himself, was found deceased at home on 22 July 2015. The cause of death was recorded as a multiple drug overdose. The principal concerns were the lack of psychotherapy provision for people with anti-social personality disorder and the absence of limits on his access to medication or community mental health support to assist with medication compliance and more frequent assessment.

Joshua James Alexander Hamill · Prevention of Future Deaths report View report

5 Dec 2017 North Wales (East and Central) J. Gittins

Joshua James Alexander Hamill, who was known to mental health services and had previously self-harmed, was reported as threatening to kill himself in the early hours of 5 June 2016. Police re-categorised the matter as a domestic incident and left him alone; he was later found dead at Flint Castle as a result of hanging. The concerns were that police training was ineffective in identifying mental health issues and that a “Concern for Safety” could be closed as a domestic incident without a recorded resolution regarding the safety and welfare of the person at risk.

Michael John Owen COX · Prevention of Future Deaths report View report

20 Jun 2019 Cornwall and Isles of Scilly A. Cox

Michael John Owen Cox had a long history of mental illness and was living at Ridgewood Care Home after being placed there in July 2016. He was found deceased in his room on 01/04/2017; the inquest jury recorded a conclusion of misadventure due to drug/alcohol use. The principal concern was the potential shortage of suitable placements for people with similar mental health histories, including persistent difficulties in finding appropriate facilities and limited resources.

David ROOMES · Prevention of Future Deaths report View report

2 Feb 2026 Kent and Medway I. Potter

David ROOMES, who had bipolar affective disorder and a relapse in depressive symptoms, was found deceased in the garage of his address on 14 April 2025, having suspended himself by ligature. The concerns included delays and shortcomings in referral triage, the absence of assessment by a qualified clinician, delays and missed opportunities for clinical review, and potential wider training issues for non-clinical decision makers.

GILLIAN O’KEEFFE · Prevention of Future Deaths report View report

28 Sep 2017 London Inner (West) A. Hodes

Gillian O’Keeffe had a serious mental illness and died at home on 19 March 2017 after taking her own life while the balance of her mind was disturbed. The concerns included her discharge from community mental health services for non-engagement despite family and professional concerns, inadequate communication with her GP and family, and the absence of a clear process for following up urgent concerns or referrals.

Ms Abigail Baynham · Prevention of Future Deaths report View report

3 Apr 2017 Black Country Z. Siddique

Ms Abigail Baynham had a history of suicidal ideation and was found deceased at her flat after taking her own life. The inquest heard that no further referral to the Mental Health Liaison Service was made when she left hospital, which may have led to a further assessment of her mental state and risk of self-harm.

Anthony Joseph McCormack · Prevention of Future Deaths report View report

27 Sep 2019 Birmingham and Solihull E. Brown

Anthony Joseph McCormack was found dead at home on 7 May 2019 after concerns about his wellbeing. He had been identified as in crisis and assessed as fit for detention, but no inpatient bed was available; concerns included inadequate assessment and monitoring by overstretched community mental health services. The inquest concluded that the death was suicide due to the unavailability of an inpatient mental health bed.

Kaye McCoy · Prevention of Future Deaths report View report

30 Jun 2023 Gwent C. Saunders

Kaye McCoy, who had depression, anxiety and Unstable Affective Disorder, died by hanging on 11 September 2022 after a severe downturn in her mental health. The report identified concerns about inadequate family involvement in her care and the lack of weekend or out-of-hours crisis support for Older Adults.

Graeme Robert Mathieson · Prevention of Future Deaths report View report

18 Jul 2018 Plymouth, Torbay and South Devon A. Cox

Graeme Robert Mathieson died following an intentional overdose of prescribed medication. The inquest concluded suicide and identified gross failures to provide basic medical attention while he was in a dependent position, which caused or contributed to the outcome. Concerns included time constraints affecting recognition of his serious psychiatric condition, confusion about mental-health care pathways, and weaknesses in transfer processes.

Robert Glyn Hughes · Prevention of Future Deaths report View report

11 Feb 2019 Gloucestershire K. Skerrett

Robert Glyn Hughes, a 67-year-old man with a history of low mood, alcohol and diazepam dependence, previous overdoses, and prostate cancer, was found deceased at home on 20 February 2018 after police responded to a concerned friend. The report records a concern that the triangle of care approach, involving permission to contact the patient’s family, was not consistently applied.

Sammi Higgins · Prevention of Future Deaths report View report

13 Dec 2019 East London N. Persaud

Sammi Higgins had mental health conditions and a deteriorating mental state, including voices telling her to harm herself. On 3 February 2018, after presenting to mental health services following an overdose and self-harm and being discharged without weekend mental health support, she ingested a fatal combination of alcohol and tablets. Concerns included the absence of an overarching care plan or key-worker, failures in communicating and implementing a medication change, and lengthy delays in accessing psychotherapy.

Lucy Amanda Jones · Prevention of Future Deaths report View report

11 Jan 2023 Gwent C. Saunders

Lucy Amanda Jones developed a serious mental illness in 2019 and died by hanging on 12 March 2022. She remained on a waiting list for Cognitive Behavioural Therapy and was not seen in the community after a planned follow-up in January 2022; attempts to contact her were limited to two phone calls, with no cold call made when she could not be contacted.

Lee Jay Bonsall · Prevention of Future Deaths report View report

31 Jan 2014 Carmarthenshire and Pembrokeshire J. Layton

Lee Jay Bonsall was found hanging from a bannister rail at his home on 3 March 2012, and the inquest recorded the medical cause of death as asphyxia by hanging, with intent unclear. Concerns related to citalopram being prescribed on repeat and the ten-month waiting time for psychotherapy.

Emma Louise MORRIS · Prevention of Future Deaths report View report

21 May 2024 Cheshire S. Murphy

Emma Louise Morris died after deliberately walking in front of a bus on 20 September 2023, following a deterioration in her mental health. A mental health practitioner had assessed that inpatient admission was clinically indicated because of an immediate risk to her safety, but no inpatient bed was available. The concern was that pressure on hospital trusts and the lack of available inpatient mental health beds could put future patients at risk of death when admission is clinically needed.

Conrad Richard James Colson · Prevention of Future Deaths report View report

26 May 2023 East London N. Persaud

Conrad Colson, who had severe body dysmorphic disorder and a previous serious suicide attempt, was found deceased at home on 2 March 2022 after friends became concerned for his welfare. The inquest concluded that he took his own life while accessing aesthetic dermatology treatment, without therapeutic medication or professional mental health support, and after discharge without a robust risk assessment or relapse risk-management plan. Concerns included insufficient liaison and information sharing between mental health services, inadequate consideration of risks associated with aesthetic dermatology treatment, and training and resource gaps relating to body dysmorphic disorder.

Steven Robert MURPHY · Prevention of Future Deaths report View report

27 Apr 2016 Portsmouth and South East Hampshire D. Horsley

On 6 June 2015, Steven Robert Murphy jumped from a footbridge at Liss railway station into the path of an oncoming train and died instantaneously. The principal concern was that South West Trains had not positively responded to a British Transport Police report recommending measures to reduce the risk of people climbing over the footbridge parapet.

Christopher Edward SIDLE · Prevention of Future Deaths report View report

25 Mar 2024 Norfolk J. Lake

Christopher Sidle had schizophrenia and experienced a deterioration in his mental health during June 2023. After several assessments by mental health services, he was not admitted to hospital; on 1 July 2023 he jumped from a moving taxi, suffered life-threatening head injuries and died on 4 July 2023 after life-sustaining therapies ceased. The report identified inadequate assessments and missed opportunities to provide appropriate and timely care, alongside concerns about crisis-team training, communication, risk assessment, community support, and the shortage of inpatient mental health beds.

Patryk Gladysz · Prevention of Future Deaths report View report

18 Jul 2025 Inner West London P. Malhotra

Patryk Gladysz, who had schizophrenia and was detained at HMP Wandsworth, was found in his cell with a ligature around his neck on 5 January 2024 and died at St George’s Hospital. The inquest concluded that he had hung himself with a ligature, with his intentions unknown. Concerns included delays and staffing pressures affecting mental health assessments, inadequate communication between prison and healthcare staff, gaps in knowledge of his history and risks, and shortcomings in prison monitoring and training.