Oxleas NHS Foundation Trust — 57 Prevention of Future Deaths reports

Reports per year

20143

2015

20162

20171

20184

20193

20204

20215

20223

20237

20248

202510

20267

Coroner categories

State Custody related deaths 13 Hospital Death (Clinical Procedures and medical management) related deaths 5 State Custody related deaths | Suicide (from 2015) 5 Suicide (from 2015) 5 Alcohol, drug and medication related deaths 4 State Custody related deaths | Mental Health related deaths | Suicide (from 2015) 3 Alcohol drugs and medication related deaths | State Custody related deaths 3 Hospital Death (Clinical Procedures and medical management) related deaths | Mental Health related deaths | Suicide (from 2015) 2 Alcohol, drugs medication related deaths | State Custody related deaths 2 State Custody related deaths | Alcohol, drug and medication related deaths 2 Mental Health related deaths 2 Alcohol, drug and medication related deaths | State Custody related deaths 2

Coroners who wrote them

Patricia Harding — 7 reports
Andrew Harris — 6 reports
Rachael Griffin — 6 reports
Scott Matthewson — 5 reports
Philip Barlow — 4 reports
Ian Brownhill — 4 reports
Ian Potter — 4 reports
Christopher Williams — 3 reports
Selena Lynch — 2 reports
Dr R N Palmer — 1 report

All reports

Date	Deceased	Category	Coroner
7 Apr 2026	Mark Smith	State Custody related deaths	Jenny Goldring	source
24 Mar 2026	Thomas Ruggiero	State Custody related deaths	Ian Potter	source
24 Mar 2026	Thomas Ruggiero	State Custody related deaths	Ian Potter	source
24 Mar 2026	Thomas Ruggiero	State Custody related deaths	Ian Potter	source
9 Feb 2026	Josh Tarrant (1)	Alcohol drugs and medication related deaths \| State Custody related deaths	Scott Matthewson	source
9 Feb 2026	Josh Tarrant (2)	Alcohol drugs and medication related deaths \| State Custody related deaths	Scott Matthewson	source
9 Feb 2026	Josh Tarrant (3)	Alcohol drugs and medication related deaths \| State Custody related deaths	Scott Matthewson	source
15 Dec 2025	Sundeep Ghuman	State Custody related deaths	David Manknell	source
29 Jul 2025	Azroy Dawes-Clarke	State Custody related deaths	Ian Brownhill	source
29 Jul 2025	Azroy Dawes-Clarke	State Custody related deaths	Ian Brownhill	source
25 Jul 2025	Sheldon Jeans	Alcohol, drug and medication related deaths \| State Custody related deaths	Rachael Griffin	source
25 Jul 2025	Michael Pugh	State Custody related deaths \| Suicide (from 2015)	Patricia Harding	source
18 Jul 2025	Patryk Gladysz	State Custody related deaths \| Mental Health related deaths	Priya Malhotra	source
30 May 2025	Colin Lovett	Alcohol, drug and medication related deaths \| State Custody related deaths	Rachael Griffin	source
11 Mar 2025	Sean Higgins	State Custody related deaths \| Mental Health related deaths \| Suicide (from 2015)	Patricia Harding	source
21 Feb 2025	Paul Dunne	Hospital Death (Clinical Procedures and medical management) related deaths \| Mental Health related deaths \| Suicide (from 2015)	Andrew Harris	source
21 Feb 2025	Luke Worrell	Mental Health related deaths	Andrew Harris	source
25 Nov 2024	Jonathon Lawlor	State Custody related deaths \| Alcohol, drug and medication related deaths	Catherine Wood	source
8 Aug 2024	Sean Davies	Suicide (from 2015)	Patricia Harding	source
19 Jul 2024	Benjamin Harrison	State Custody related deaths \| Alcohol, drug and medication related deaths	Patricia Harding	source
27 Jun 2024	Emily Collishaw	Alcohol, drug and medication related deaths	Andrew Harris	source
31 May 2024	Frazer Williams	State Custody related deaths \| Suicide (from 2015)	Rachael Griffin	source
17 May 2024	Jada Monoja	Suicide (from 2015)	Xavier Mooyaart	source
4 Mar 2024	Lee Hughes	Alcohol, drug and medication related deaths	Fiona Wilcox	source
2 Feb 2024	Samuel Jordan	Suicide (from 2015)	Nicholas Rheinberg	source
21 Dec 2023	Denise Porter	Suicide (from 2015)	Hannah Hinton	source
5 Dec 2023	Samuel Jones	State Custody related deaths	Rachael Griffin	source
27 Nov 2023	Luke Whitelaw	Suicide (from 2015)	Ian Potter	source
3 Jul 2023	Liam Bentley	State Custody related deaths \| Suicide (from 2015)	Patricia Harding	source
2 Feb 2023	Jason Williams	Alcohol, drugs medication related deaths \| State Custody related deaths	Rachael Griffin	source
31 Jan 2023	Nathan Forrester	Alcohol, drugs medication related deaths \| State Custody related deaths	Andrew Harris	source
17 Jan 2023	John Henderson	State Custody related deaths	Ian Brownhill	source
10 Nov 2022	Samuel Pearson	Alcohol, drug and medication related deaths	Jonathan Landau	source
8 Nov 2022	Liridon Saliuka	State Custody related deaths \| Suicide (from 2015)	Philip Barlow	source
24 Oct 2022	Bradleigh Barnes	State Custody related deaths \| Suicide (from 2015)	Rachael Griffin	source
4 Nov 2021	Christian Hinkley	State Custody related deaths	Scott Matthewson	source
4 Oct 2021	Caden Stewart	State Custody related deaths \| Child Death (from 2015)	Patricia Harding	source
10 Sep 2021	Lee Thrumble	State Custody related deaths \| Suicide (from 2015) \| Mental Health related deaths	Scott Matthewson	source
25 May 2021	James Devenny	State Custody related deaths \| Mental Health related deaths \| Suicide (from 2015)	Ian Brownhill	source
10 Feb 2021	Jason O’Rourke	State Custody related deaths \| Mental Health related deaths \| Suicide (from 2015)	Henrietta Hill QC	source
11 Dec 2020	Claire Lilley	Hospital Death (Clinical Procedures and medical management) related deaths \| Mental Health related deaths \| Suicide (from 2015)	Dr Julian Morris	source
18 Aug 2020	Viktor Scott-Brown	Suicide; Community healthcare related deaths	Oliver Longstaff	source
26 Jun 2020	Gary Etherington	Mental Health related deaths; Community healthcare related deaths; Suicide	Andrew Harris	source
21 Feb 2020	Billy Jenkins	Alcohol, drug and medication related deaths; Mental Health related deaths; Community health care related death; Suicide (from 2015)	Jacqueline Devonish	source
28 Jun 2019	Feni Lee	Community health care related deaths	Philip Barlow	source
8 May 2019	Bernard O’Flynn	State Custody related deaths	Christopher Williams	source
15 Apr 2019	Jennifer Lewis	Hospital Death (Clinical Procedures and medical management) related deaths	Roger Hatch	source
29 Oct 2018	Thomas McAuley	State Custody related deaths	Andrew Harris	source
27 Sep 2018	Julia MacPherson	Hospital Death (Clinical Procedures and medical management) related deaths	Sonia Hayes	source
12 Feb 2018	John Sloan	Mental Health related deaths	Christopher Williams	source
29 Jan 2018	Michael Vukovic	Hospital Death (Clinical Procedures and medical management) related deaths	Philip Barlow	source
18 Dec 2017	Anne Morris	Hospital Death (Clinical Procedures and medical management) related deaths	Christopher Williams	source
5 Dec 2016	Christopher Brennan	Child Death (from 2015); Hospital Death (Clinical Procedures and medical management) related deaths	Selena Lynch	source
18 May 2016	Ratidzai Sangare	Hospital Death (Clinical Procedures and medical management) related deaths	Selena Lynch	source
28 Dec 2014	Alex Kelly	State Custody related deaths	Patricia Harding	source
27 Oct 2014	Philip Allen	Community health care and emergency services related deaths	Philip Barlow	source
31 Mar 2014	Deanne Smith	Alcohol, drug and medication related deaths	Dr R N Palmer	source

These counts are a floor, not a total. A report is listed here only when it names the organisation in text our pipeline could read; scanned reports with poor OCR, and reports that name only a hospital site or an individual, are missed. Always check the source report.

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