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Tony Montana Duncan · Prevention of Future Deaths report View report

15 Oct 2025 City of London A. Hewitt

Tony Montana Duncan had a long-term mental health condition and, during an acute deterioration, told healthcare services that he had suicidal thoughts and planned to jump from a bridge. He was assessed by a psychiatric liaison team and discharged without medication review, admission, documented risk assessment, or follow-up safeguarding, despite information about his suicide plan. On 4 July 2024, he jumped into the River Thames and likely died shortly afterwards; the report identified concerns about the response of mental health services to the risks he presented.

Tracey Ostler · Prevention of Future Deaths report View report

4 Aug 2025 Surrey C. Topping

Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.

Bronwen Grace MORGAN (BM) · Prevention of Future Deaths report View report

25 Oct 2023 South Wales Central G. Hughes

Bronwen Morgan, who was under the care of local mental health services, travelled to a hotel on 27 August 2020 and was later found there by emergency services. She was conveyed to hospital, where she died from the toxic consequences of a substance after resuscitation attempts failed. The principal concern was that an online forum and potentially similar sites enabled vulnerable people to discuss, obtain information about, and acquire means for self-harm or suicide.

Mr Bradley Fraser Brown · Prevention of Future Deaths report View report

30 Nov 2018 Manchester North L. Hashmi

Mr Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.

James Edward Boylan · Prevention of Future Deaths report View report

6 Jun 2014 South and East Cumbria I. Smith

James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.

Martyn Harvey Stringer · Prevention of Future Deaths report View report

7 Aug 2024 Oxfordshire N. Graham

Martyn Harvey Stringer was detained by police after being found at a location where he had ostensibly gone to take his own life, and was assessed as liable for detention under Section 2 of the Mental Health Act. No suitable mental health placement was found, and he later left home and stepped in front of a lorry; he died on 29 March 2023 from multi-organ failure and polytrauma resulting from a road traffic collision. The principal concern was the lack of suitable beds and placements for people requiring compulsory mental health treatment, including the decision not to offer an available Health Based Place of Safety bed to Martyn.

Paul Price · Prevention of Future Deaths report View report

18 Sep 2018 Birmingham and Solihull L. Hunt

Paul Price had a history of depression and anxiety, and was found outside his room on 04/06/18 after falling from a window; he was pronounced deceased at hospital, with the medical cause of death recorded as multiple injuries. Concerns included delays in communicating mental-health assessment information to his GP, incompatible IT systems, and a failure to return a call about concerns for his wellbeing.

Meghan Irene CHRISMAS · Prevention of Future Deaths report View report

29 Dec 2023 Surrey D. Stewart

Meghan Irene CHRISMAS attempted suicide by hanging on 18 October 2021 and, after resuscitation, died two days later on 20 October 2021 from a hypoxic brain injury. The report raised concerns about the delayed handling and supervision of communications in the Hampshire Police Force Control Room and the absence of an adequate structure for sharing important clinical information between NHS and private healthcare providers.

Timothy Robert DE BOOS · Prevention of Future Deaths report View report

13 Dec 2024 Suffolk N. Parsley

Timothy Robert DE BOOS was declared deceased at his home in Ipswich on 6 February 2024 after a self-inflicted domestic fire, with the medical cause of death recorded as smoke inhalation and severe burns. The report raises concerns about the lack of available Mental Health Unit inpatient beds and about the admission process when the patient, family, and an experienced mental health professional considered voluntary admission necessary.

Michaela Louise Thompson · Prevention of Future Deaths report View report

2 Nov 2016 West Yorkshire (East) D. Hinchliff

Michaela Louise Thompson, who had a history of depression and regular suicidal thoughts, died by self-suspension at home on 1 December 2015. Concerns included inadequate documentation of multidisciplinary team meetings and the failure to record and promptly communicate a distressing telephone call to mental health services on the morning of her death.

John Peter MCLOUGHLIN · Prevention of Future Deaths report View report

6 Mar 2025 West Sussex, Brighton and Hove G. Jones

John Peter McLoughlin, a pilot employed by West Atlantic UK, died by suicide in a Brighton hotel bathroom on 19 July 2023 while attending a stressful and highly pressured training course. The report raised concerns that peer support from trained mental health first aiders was inadequate for pilots experiencing severe mental health difficulties and suicidal thoughts, and that wider industry support was insufficient when problems escalated.

Christopher Michael Lloyd · Prevention of Future Deaths report View report

26 Aug 2022 Manchester South C. Morris

Christopher Michael Lloyd died at home after suspending himself by the neck with a ligature. The principal concern was that, despite interactions with mental health services and support for alcohol and drug addiction, he did not have ready local access to a dual-diagnosis service for co-existing mental-health and substance-misuse issues.

Susan Mary Regan · Prevention of Future Deaths report View report

17 Aug 2022 Manchester South C. Murray

Susan Mary Regan, aged 61, experienced deteriorating mental and physical health, including malnutrition, dehydration, disturbed behaviour and possible self-harm, before being admitted to hospital and later discharged with support. On 25 July 2020, she took her own life at home. The principal concerns were that the Home Treatment Team did not consult her sons about possible hospitalisation and did not properly record or communicate a care plan with them.

Jennifer Sarah Myfanwy SPENCER · Prevention of Future Deaths report View report

18 Dec 2020 East Sussex J. Healy-Pratt

Jennifer Sarah Myfanwy Spencer's mental health deteriorated after she ingested Shamanic hallucinogenic drugs and practised Kundalini Yoga, before she deliberately fell from Beachy Head on 16 November 2019 intending to end her life. The report identifies a lack of awareness among mental health professionals about Shamanic hallucinogens and their potential to cause or exacerbate psychosis, resulting in sub-optimal assessment, treatment and care.

Alistair Patrick McDonald · Prevention of Future Deaths report View report

29 Jul 2019 Manchester City N. Meadows

Alistair Patrick McDonald, who had disclosed suicidal thoughts and a history of deliberate self-harm, was found dead on 14 May 2018, hanging by a ligature secured to a door frame. The concerns included the assessment and management of his suicidal ideation and self-harm, lack of follow-up and clear referral plans, communication with him and his family, and failure to recognise the wider significance of his presentation.

Haik Patrick NIKOLYAN · Prevention of Future Deaths report View report

15 Aug 2023 Buckinghamshire C. Butler

Haik Patrick NIKOLYAN committed suicide and was found unresponsive in his cell at HMYOI Aylesbury in the early hours of 11 March 2019. The inquest identified concerns including failures to protect him from harm, withdrawal of depression medication without documented risk assessment or enhanced monitoring, bullying and exploitation, ineffective safeguarding and communication, and inadequate consideration of his Autism Spectrum Disorder.

Rebecca Jayne Flint · Prevention of Future Deaths report View report

17 Jul 2022 Manchester South A. Farrow

Rebecca Flint was under the care of the Trafford Community Mental Health Team and was found at home on 7 September 2020. The report raised concerns about inconsistent Care Coordinator roles between Trusts and limited Community Mental Health Team resources, including the absence of cover when a Care Coordinator was unavailable.

Daniel Watson · Prevention of Future Deaths report View report

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

Daniel Watson was found hanged at his home on 5 June 2017 and was verified dead from hanging. The report identified care and service delivery problems, missed opportunities to improve his mental health, and concerns about staff understanding of risk assessment and escalation towards formal psychiatric assessment.

Mr Bromley · Prevention of Future Deaths report View report

19 Sep 2019 Manchester South C. Morris

Mr Bromley was receiving support from the Home Treatment Team after declining an informal hospital admission. He was found dead on 18 February 2019 at his gym, having suspended himself by the neck with a ligature; the inquest recorded a conclusion of suicide. The concerns related to the Home Treatment Team’s lack of a dedicated Consultant Psychiatrist, uncertainty about recruitment to such a post, and the patchy operation of interim psychiatric access arrangements.

Samarjit Natasha SINGH · Prevention of Future Deaths report View report

23 May 2014 The Wirral A. Rebello

Samarjit Natasha Singh developed postnatal depression after giving birth to her son and had acts of deliberate self-harm and a threat of self-harm. On 4 December 2012, she was found in cardiac arrest following hanging and sustained an irreversible hypoxic brain injury; she died the following day. The report identified concerns about the absence of a Specialist Community Perinatal Mental Health Service and a Mother and Baby Perinatal Mental Health inpatient unit in the Liverpool City Region.