Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0638, written 19 Dec 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 Dec 2025 |
|---|---|
| Reference | 2025-0638 |
| Deceased | Jason White |
| Coroner | Nicola Mundy |
| Coroner area | South Yorkshire (East) |
| Category | Suicide (from 2015) |
| Organisation named | Sheffield Teaching Hospitals NHS Foundation Trust · Sheffield Health Partnership University NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
MS N J MUNDY H M CORONER SOUTH YORKSHIRE (East District) email: CORONER’S COURT AND OFFICE CROWN COURT COLLEGE ROAD DONCASTER DN1 3HS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Partnership, University NHS Foundation Trust 1. CORONER , Sheffield Health I am Ms N J Mundy for South Yorkshire East 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 20 December 2024 I commenced an investigation into the death of Jason Ricardo White. The investigation concluded at the end of the inquest . The conclusion of the inquest was Suicide. The cause of death was: 1a 4. CIRCUMSTANCES OF THE DEATH Jason Ricardo White developed mental health symptoms in April 2024 which were essentially depression and psychotic episodes. Mr White engaged with both his GP and mental health support services including the Priory hospital in Nottingham, Sheffield Teaching Hospitals NHS Trust, Sheffield Health Partnership University NHS Foundation Trust, and Sheffield City Council to manage his symptoms. He remained fixated on his symptoms being linked to serious medical complaints and appeared at no time to accept that the physical symptomology of which he complained was inextricably linked to his mental health challenges. Mr White received various levels of management which included medication. One of those medications was olanzapine. This was ceased abruptly due to a belief that this was responsible for deranged liver function tests but there was inadequate follow-up thereafter. As it was Mr White died from on the 10th of December 2024 5. CORONER’S CONCERNS . During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. Antipsychotic medication (Olanzapine) abruptly ceased and the management plan of daily monitoring was not followed. 2. This created a risk of relapse in terms of psychotic symptoms and associated deterioration in mental health. 3. Risks of relapse when any medication is abruptly ceased. Must be fully monitored; the absence of full assessment and monitoring exposes patients to risk of a serious deterioration in mental health. 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by the 13th February 2026. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Sheffield City Council and Priory Healthcare. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 19 December 2025 9. Signature Ms N. J . Mundy LL.B (hons) Senior Coroner for South Yorkshire East
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
6 February 2026 PRIVATE & CONFIDENTIAL Ms N J Mundy HM Senior Coroner (South Yorkshire East) The Coroners Court and Office Crown Court Building College Road Doncaster DN1 3HS Sent via email Dear Ms Mundy Executive Medical Director Sheffield Health Partnership University NHS Foundation Trust Trust Headquarters 2nd Floor, Centre Court Atlas Way Sheffield S4 7QQ Email: Website: www.sheffieldpartnership.nhs.uk Prevention of Future Deaths Report issued following the Inquest touching the death of Mr Jason White - DoB 28/02/1969 I am writing in connection with the Prevention of Future Deaths Report issued following the above inquest that was heard before you between 20 December 2024 and 3 December 2025. During the inquest, you identified areas of concern arising from the evidence presented, specifically: 1. The abrupt cessation of antipsychotic medication (Olanzapine) and the failure to follow the agreed management plan of daily monitoring. 2. The resulting increased risk of relapse, including the return of psychotic symptoms and deterioration in mental health. 3. The wider risk associated with abrupt cessation of medication without full assessment and appropriate monitoring, potentially exposing patients to serious deterioration in their mental wellbeing. As a direct response to the learning from this case, we have strengthened our approach to monitoring service users following changes to antipsychotic medication. These improvements are already being implemented in practice, with full standardisation across all relevant services to be completed by 1 March 2026. Specifically, any request for enhanced monitoring following medication changes is now formally logged and reviewed at the first daily multidisciplinary planning meeting (commonly referred to as the “huddle”). This ensures immediate visibility, shared clinical oversight, and timely decision- making. The process includes: 1. A structured clinical discussion to confirm the level of risk and the intensity of monitoring required. Where monitoring is required more than two to three times per week, referral to the Home Treatment Team is actively considered. 2. Clear allocation of responsibility to a named clinician, ensuring ownership and continuity of follow-up. 3. Where immediate follow-up cannot be undertaken, the requirement is formally recorded within the clinical diary system to ensure oversight and action by the duty team. These arrangements are already operating within Community Mental Health Teams and are being embedded consistently across all teams to ensure a reliable and auditable approach. In parallel, routine planned appointments with service users continue, providing ongoing clinical review, continuity of care and further opportunities for early identification of relapse or deterioration. Collectively, these actions represent a significant strengthening of our systems for managing medication changes. They reinforce shared clinical responsibility, improve visibility of risk and ensure that monitoring arrangements are clear, proactive and responsive. Most importantly, they place patient safety at the forefront of care delivery following medication changes. I hope this response provides assurance that the concerns identified during the inquest have been carefully considered and that meaningful, sustained improvements are underway. Please do not hesitate to contact me should you require any further information. On behalf of Sheffield Health Partnership University NHS Foundation Trust, I would like once again to extend our sincere condolences to Mr White’s family. Yours sincerely Executive Medical Director cc: , Chief Executive NHS Sheffield Integrated Care Board
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