Reviewed 7 October 2026 · records beside the claims
People harmed: the case register
People, care contexts, documented failures and responses — separate from Matthew Bayliss’s personal case.
13 reviewed records: 12 deaths and one serious-harm case. Every entry identifies its source type. This is an expanding register, not a national death count. INQUEST entries are attributed to its case archive; they are not presented as independently re-examined court files.
Content includes death, sexual-assault reports, restraint and seclusion. Descriptions avoid procedural detail. Read at your own pace.
Died on 15 November 2012, eight days after admission.
Findings, response and records
What the reviewed evidence establishes
PHSO identified inadequate risk management and observations, a care plan completed after death, and inadequate action on his report of rape.
Response and accountability
The trust initially described care as good. PHSO later found serious failures and sought an action plan.
What the record still does not answer
His report of rape is recorded; its occurrence is not resolved by this summary. The full family testimony and the institutional findings must both be read.
Tentative ADHD and dissocial personality disorder diagnoses; Linden Centre
Died during an inpatient admission in December 2008.
Findings, response and records
What the reviewed evidence establishes
PHSO found missed opportunities to reduce suicide risk, inadequate medication monitoring, ward-leave risk assessment and care planning.
Response and accountability
An internal investigation and inquest preceded the ombudsman investigation. The family experienced continuing injustice from deficient care.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Died from cocaine toxicity on 10 June 2024 after four years on the ADHD waiting list.
Findings, response and records
What the reviewed evidence establishes
The coroner raised national concern about high-risk people awaiting ADHD assessment without treatment or monitoring. Additional funding had not significantly reduced his wait.
Response and accountability
The 20 December 2024 report required a response from NHS England, with actions and a timetable or an explanation for no action.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Detained mental health inpatient; Woodbourne Priory
Died after leaving the hospital courtyard during his admission in September 2020.
Findings, response and records
What the reviewed evidence establishes
The inquest found neglect contributed to death. The report identified inadequate risk assessment, documentation and courtyard security, including missed learning from previous escapes.
Response and accountability
CQC reported a guilty plea and a total payment of £693,852 in March 2024. A provider response is published with the coroner report.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Death · INQUEST case archive reporting formal findings
Age
18
Gender / source description
Boy
Care context
Autism, learning disabilities and epilepsy; Southern Health assessment unit
Drowned following an epileptic seizure while bathing alone in 2013.
Findings, response and records
What the reviewed evidence establishes
INQUEST records an inquest finding that neglect contributed to death and an independent investigation finding that the death was preventable, with failures in epilepsy management.
Response and accountability
The unit closed. His family pursued the failures in care and communication.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
ADHD and autism; education, health and multi-agency support
The 2024 inquest concluded suicide.
Findings, response and records
What the reviewed evidence establishes
The coroner recorded failures to communicate needs and coordinate support. A mistaken belief that schools first had to spend £6,000 was delaying statutory needs assessments.
Response and accountability
The report acknowledged some concerns had been addressed and called for action on the remaining assessment barrier.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Suicidal distress; autism assessment and therapy waiting lists
Died by suicide on 4 March 2021 while still waiting for therapy.
Findings, response and records
What the reviewed evidence establishes
Therapy stopped when a therapist left. Further intervention was deferred during a 22-month autism assessment process. The coroner raised national concerns about long waits and monitoring.
Response and accountability
Reports were sent to NHS England, the ICB and the council. Local assessment and monitoring plans still needed commissioning input at the inquest.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Depression, self-harm and autism diagnosis; discharge after detention
Died by suicide on 16 October 2020 following discharge in August.
Findings, response and records
What the reviewed evidence establishes
The coroner recorded failures in requested social-care assessments and coordinated aftercare that contributed to death. Statutory confusion delayed reopening the case.
Response and accountability
The report sought action on diagnosis, joined-up assessment and aftercare responsibilities.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Died in April 2024; the coroner issued a report on 4 November 2024.
Findings, response and records
What the reviewed evidence establishes
The coroner was concerned that the college lacked current information after treatment and support ended, and that communication between agencies had not been maintained.
Response and accountability
A formal response was required. The public report redacts its recipient and refers to a separate narrative conclusion.
What the record still does not answer
The recipient is redacted. The separate narrative conclusion is not reproduced here; these limits do not establish why other records are unavailable.
Autistic looked-after child; St Andrew’s Healthcare
Prolonged seclusion and restrictive care; this is a living person’s case, not a death record.
Findings, response and records
What the reviewed evidence establishes
The 2019 review found unmet needs, harmful restriction, weak safeguarding, poor regulatory follow-up and urgent actions with little impact.
Response and accountability
NHS England conducted the review for the Secretary of State. It proposed coordinated planning, human-rights scrutiny, community provision and escalation.
What the record still does not answer
Only an excerpt was published. DHSC explicitly cites confidentiality and privacy as reasons; the page does not recast that as proof of deliberate concealment.
Died by suicide while an inpatient. INQUEST records repeated restraint and sedative injections.
Findings, response and records
What the reviewed evidence establishes
INQUEST records an inquest finding that neglect contributed to death and a guilty plea to health and safety breaches.
Response and accountability
The Priory was fined £300,000. Her mother Tania campaigned for accountability; Amy’s sister continued after Tania’s death.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Death · INQUEST case archive reporting formal findings
Age
17
Gender / source description
Transgender boy
Care context
ADHD; suspected autism; Junction 17 children’s inpatient unit
Died after a self-harm incident following return from home leave.
Findings, response and records
What the reviewed evidence establishes
INQUEST records a 2024 jury conclusion that he did not intend to die, alongside failures in inter-service engagement and family support.
Response and accountability
His mother Samantha continues to campaign. The archive links his pen portrait and the April 2024 prevention report.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Death · INQUEST case archive reporting formal findings
Age
35
Gender / source description
Woman
Care context
Autism diagnosed in adulthood; anorexia, anxiety and OCD; Pathway House
Died after being struck by a lorry in July 2016 while missing from her placement.
Findings, response and records
What the reviewed evidence establishes
INQUEST records a full inquest, secured after a legal battle, which identified an avoidable tragedy and multiple care-home failures.
Response and accountability
Her parents Andy and Amanda published a memoir and spoke publicly about the fight to secure scrutiny.
What the record still does not answer
The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.
Records not obtained or not published are labelled by that precise status. We identify refusal, redaction, withheld material or deliberate concealment only where the reviewed evidence supports it. Not knowing a fact does not invalidate a person’s testimony.