[ { "id": "matthew-leahy", "name": "Matthew Leahy", "age": "20", "gender": "Man", "context": "Psychosis service; detained at the Linden Centre", "outcome": "Death", "incident": "Died on 15 November 2012, eight days after admission.", "finding": "PHSO identified inadequate risk management and observations, a care plan completed after death, and inadequate action on his report of rape.", "response": "The trust initially described care as good. PHSO later found serious failures and sought an action plan.", "url": "https://www.ombudsman.org.uk/publications/missed-opportunities-what-lessons-can-be-learned-failings-north-essex/our-investigations", "source_type": "Ombudsman finding", "records_gap": "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.", "checked": "2026-10-07" }, { "id": "mr-r", "name": "Mr R", "age": "20", "gender": "Man", "context": "Tentative ADHD and dissocial personality disorder diagnoses; Linden Centre", "outcome": "Death", "incident": "Died during an inpatient admission in December 2008.", "finding": "PHSO found missed opportunities to reduce suicide risk, inadequate medication monitoring, ward-leave risk assessment and care planning.", "response": "An internal investigation and inquest preceded the ombudsman investigation. The family experienced continuing injustice from deficient care.", "url": "https://www.ombudsman.org.uk/publications/missed-opportunities-what-lessons-can-be-learned-failings-north-essex/our-investigations", "source_type": "Ombudsman finding", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "oliver-winson", "name": "Oliver Winson", "age": "33", "gender": "Man", "context": "Adult ADHD assessment waiting list; substance misuse services", "outcome": "Death", "incident": "Died from cocaine toxicity on 10 June 2024 after four years on the ADHD waiting list.", "finding": "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": "The 20 December 2024 report required a response from NHS England, with actions and a timetable or an explanation for no action.", "url": "https://www.judiciary.uk/prevention-of-future-death-reports/oliver-winson-prevention-of-future-deaths-report/", "source_type": "Coroner report", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "matthew-caseby", "name": "Matthew Caseby", "age": "Age not stated in the reviewed report extract", "gender": "Man", "context": "Detained mental health inpatient; Woodbourne Priory", "outcome": "Death", "incident": "Died after leaving the hospital courtyard during his admission in September 2020.", "finding": "The inquest found neglect contributed to death. The report identified inadequate risk assessment, documentation and courtyard security, including missed learning from previous escapes.", "response": "CQC reported a guilty plea and a total payment of £693,852 in March 2024. A provider response is published with the coroner report.", "url": "https://www.judiciary.uk/prevention-of-future-death-reports/matthew-caseby-prevention-of-future-deaths-report/", "source_type": "Coroner report", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "connor-sparrowhawk", "name": "Connor Sparrowhawk", "age": "18", "gender": "Boy", "context": "Autism, learning disabilities and epilepsy; Southern Health assessment unit", "outcome": "Death", "incident": "Drowned following an epileptic seizure while bathing alone in 2013.", "finding": "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": "The unit closed. His family pursued the failures in care and communication.", "url": "https://history.inquest.org.uk/case-profiles/connor-sparrowhawk/", "source_type": "INQUEST case archive reporting formal findings", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "jennifer-chalkley", "name": "Jennifer Chalkley", "age": "17", "gender": "Girl", "context": "ADHD and autism; education, health and multi-agency support", "outcome": "Death", "incident": "The 2024 inquest concluded suicide.", "finding": "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": "The report acknowledged some concerns had been addressed and called for action on the remaining assessment barrier.", "url": "https://www.judiciary.uk/prevention-of-future-death-reports/jennifer-chalkley-prevention-of-future-deaths-report/", "source_type": "Coroner report", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "joshua-weavers", "name": "Joshua Weavers", "age": "17", "gender": "Boy", "context": "Suicidal distress; autism assessment and therapy waiting lists", "outcome": "Death", "incident": "Died by suicide on 4 March 2021 while still waiting for therapy.", "finding": "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": "Reports were sent to NHS England, the ICB and the council. Local assessment and monitoring plans still needed commissioning input at the inquest.", "url": "https://www.judiciary.uk/prevention-of-future-death-reports/joshua-weavers-prevention-of-future-deaths-report/", "source_type": "Coroner report", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "molly-ann-sergeant", "name": "Molly-Ann Sergeant", "age": "17", "gender": "Girl", "context": "Depression, self-harm and autism diagnosis; discharge after detention", "outcome": "Death", "incident": "Died by suicide on 16 October 2020 following discharge in August.", "finding": "The coroner recorded failures in requested social-care assessments and coordinated aftercare that contributed to death. Statutory confusion delayed reopening the case.", "response": "The report sought action on diagnosis, joined-up assessment and aftercare responsibilities.", "url": "https://www.judiciary.uk/prevention-of-future-death-reports/molly-ann-sergeant-prevention-of-future-deaths-report/", "source_type": "Coroner report", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "henry-grierson", "name": "Henry Grierson", "age": "17", "gender": "Boy", "context": "CAMHS, Recovery Steps and college safeguarding", "outcome": "Death", "incident": "Died in April 2024; the coroner issued a report on 4 November 2024.", "finding": "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": "A formal response was required. The public report redacts its recipient and refers to a separate narrative conclusion.", "url": "https://www.judiciary.uk/prevention-of-future-death-reports/henry-grierson-prevention-of-future-deaths-report/", "source_type": "Coroner report", "records_gap": "The recipient is redacted. The separate narrative conclusion is not reproduced here; these limits do not establish why other records are unavailable.", "checked": "2026-10-07" }, { "id": "beth", "name": "Beth / Bethany", "age": "17 when the case became public", "gender": "Girl", "context": "Autistic looked-after child; St Andrew’s Healthcare", "outcome": "Serious harm", "incident": "Prolonged seclusion and restrictive care; this is a living person’s case, not a death record.", "finding": "The 2019 review found unmet needs, harmful restriction, weak safeguarding, poor regulatory follow-up and urgent actions with little impact.", "response": "NHS England conducted the review for the Secretary of State. It proposed coordinated planning, human-rights scrutiny, community provision and escalation.", "url": "https://assets.publishing.service.gov.uk/media/5dc58c73e5274a4eb55909a0/Serious_incident_investigation_report_-_Secretary_of_State_case_review_into_Beth.pdf", "source_type": "Government-published independent review", "records_gap": "Only an excerpt was published. DHSC explicitly cites confidentiality and privacy as reasons; the page does not recast that as proof of deliberate concealment.", "checked": "2026-10-07" }, { "id": "amy-el-keria", "name": "Amy El-Keria", "age": "14", "gender": "Girl", "context": "Complex mental ill health; NHS-funded Priory children’s hospital", "outcome": "Death", "incident": "Died by suicide while an inpatient. INQUEST records repeated restraint and sedative injections.", "finding": "INQUEST records an inquest finding that neglect contributed to death and a guilty plea to health and safety breaches.", "response": "The Priory was fined £300,000. Her mother Tania campaigned for accountability; Amy’s sister continued after Tania’s death.", "url": "https://history.inquest.org.uk/case-profiles/amy-el-keria/", "source_type": "INQUEST case archive reporting formal findings", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "charlie-millers", "name": "Charlie Millers", "age": "17", "gender": "Transgender boy", "context": "ADHD; suspected autism; Junction 17 children’s inpatient unit", "outcome": "Death", "incident": "Died after a self-harm incident following return from home leave.", "finding": "INQUEST records a 2024 jury conclusion that he did not intend to die, alongside failures in inter-service engagement and family support.", "response": "His mother Samantha continues to campaign. The archive links his pen portrait and the April 2024 prevention report.", "url": "https://history.inquest.org.uk/case-profiles/charlie-millers/", "source_type": "INQUEST case archive reporting formal findings", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" }, { "id": "colette-mcculloch", "name": "Colette McCulloch", "age": "35", "gender": "Woman", "context": "Autism diagnosed in adulthood; anorexia, anxiety and OCD; Pathway House", "outcome": "Death", "incident": "Died after being struck by a lorry in July 2016 while missing from her placement.", "finding": "INQUEST records a full inquest, secured after a legal battle, which identified an avoidable tragedy and multiple care-home failures.", "response": "Her parents Andy and Amanda published a memoir and spoke publicly about the fight to secure scrutiny.", "url": "https://history.inquest.org.uk/case-profiles/colette-mcculloch/", "source_type": "INQUEST case archive reporting formal findings", "records_gap": "The reviewed source does not establish whether every corrective action was completed. This is an implementation question, not a finding that no action occurred.", "checked": "2026-10-07" } ]