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<\/p>\nNottinghamshire Healthcare NHS Foundation Trust has been heavily criticised over the years<\/p>\n
Kaine Fletcher, a dad-of-two, died in 2022(Image: Family handout)<\/p>\n
Nottinghamshire coroners have repeatedly warned that more deaths could occur because of failures at the organisation responsible for mental health care in Nottinghamshire.<\/p>\n
Substandard care due to staffing levels, a lack of handovers and failures to follow up appointments are just some of the issues identified by coroners across Nottinghamshire Healthcare NHS<\/a> Foundation Trust (NHFT).<\/p>\n The trust was assessed 39 times by the Care Quality Commission between May 2024 and August 2025, having been at the centre of multiple scandals in recent years.<\/p>\n NHFT currently holds the top position in Nottinghamshire for the number of Prevention of Future Deaths Reports issued by coroners since 2013, totalling 29, according to the Preventable Death Tracker.<\/p>\n This is 17 times more than the next Nottinghamshire organisation in the rank – Nottingham University Hospitals<\/a> NHS Trust.<\/p>\n PFD reports are issued by coroners under the Coroners and Justice Act 2009 to a person, organisation, local authority, government department or agency where the coroner believes that action should be taken to prevent future deaths.<\/p>\n Below is an overview of all the times NHFT was told to do better by coroners since 2024.<\/p>\n Sophie Towle<\/p>\n Sophie Towle<\/a> died aged 22 on May 27, 2024, from a pulmonary thromboembolus at King’s Mill Hospital whilst she was detained under section 3 of the Mental Health Act 1983.<\/p>\n She had been receiving treatment there after a self-harming incident on May 12 left her unable to walk, which eventually caused a blood clot to form in her leg<\/a> and move to her lung, causing the pulmonary embolism.<\/p>\n A jury inquest was held into her death in front of coroner Alexandra Pountney in October 2025, revealing a litany of failures by NHFT in Sophie’s care.<\/p>\n Sophie enjoyed the theatre and cooking(Image: Leisa Towle)<\/p>\n Sophie, from Mapperley<\/a>, had been in and out of mental health facilities since 2021.<\/p>\n She was transferred to Sherwood Oaks, run by NHFT, in April 2024, but when she got there, there was no body mapping done, no wound care done, no assessment care plan made, no weight management care plan made, no reassessment of her blood clot risk and an inconsistent care plan with regards to her physical observations.<\/p>\n Two weeks later, on May 12, Sophie self-harmed again while on 24\/7 observations with a healthcare assistant sitting in the doorway watching her.<\/p>\n The jury found that Sophie’s care was ‘substandard’ due to staffing levels and a lack of staff experience, with a reliance on agency staff who didn’t necessarily know Sophie.<\/p>\n There was no continuity of care and a lack of policy awareness and compliance.<\/p>\n Due to the damning string of errors<\/a>, coroner Alexandra Pountney warned that action should be taken by staff at NHFT to prevent future deaths in circumstances similar to Sophie’s.<\/p>\n James Southern James Southern, who was known to his friends and family as ‘Jimmy'(Image: Rothera Bray)<\/p>\n Had staff at NHFT communicated and kept better records, <\/a>James Southern<\/a>, known as Jimmy, might still be here.<\/p>\n The 40-year-old grandad was found unresponsive by his father at his home address in Cotgrave on May 31, 2023.<\/p>\n Mr Southern had been suffering with pain and anxiety since a motorbike crash in 2002 and had spent almost a month at Highbury Hospital in 2022.<\/p>\n Despite being known to self-medicate to cope with his pain and anxiety and being known to NHFT, he was not seen by services in the months leading up to his death.<\/p>\n An inquest held by coroner Sarah Wood in October 2024 heard that Mr Southern died as a result of polydrug toxicity.<\/p>\n The inquest also found his case had not been passed on when his care coordinator went on long-term sick leave, and she did not try to contact him when she returned to work, leaving him without care in the months leading up to his death.<\/p>\n It also uncovered that staff had changed Mr Southern\u2019s clinical records after he died. Ms Wood said failings at NHFT “more likely than not” contributed to his death.<\/p>\n Ms Wood issued a Prevention of Future Deaths Report, saying she was concerned about potentially ongoing issues of poor record-keeping and poor communication between the trust\u2019s staff members and patients.<\/p>\n Anthony Binfield, David Richards and Rolandas Karbauskas Family handouts of Anthony Binfield pictured as a child and David Richards and a mugshot of Rolandas Karbauskas(Image: DPG\/Lincolnshire Police)<\/p>\n Anthony Binfield, 30, David Richards, 42, and Rolandas Karbauskas, 49<\/a>, all died at Lowdham Grange after being found with ligatures around their necks in March 2023.<\/p>\n At the time of the three deaths, NHFT was the healthcare provider at HMP Lowdham Grange, with the trust exiting prison healthcare contracts in the East Midlands by mid-2025.<\/p>\n The first of the three deaths took place just six weeks after the management of the prison changed hands from Serco to Sodexo, believed to be the first private-to-private company transfer.<\/p>\n The jail was permanently taken over by the Government<\/a> just over a year later due to deteriorating safety, prisoner conditions, and staffing levels.<\/p>\n The jury inquest, which began in November 2024 and concluded in February 2025, revealed “various shortcomings in culture and system processes with regard to both prison and healthcare”.<\/p>\n Mr Binfield’s mental health deteriorated significantly between March 3 and 6, with the prison missing “ample” opportunities to safeguard him.<\/p>\n The jury found that the father “felt trapped by the system, out of depth, and he felt he had no one to turn to for help”, passing away on March 6.<\/p>\n Mr Richards was found dead in his cell on March 13 by another prisoner, only a few weeks after his transfer from another jail.<\/p>\n Staff at Lowdham Grange failed to identify him as a vulnerable prisoner, which affected his mental health and made him “a rabbit in the headlights”<\/p>\n Mr Karbauskas was also found dead by a fellow inmate 12 days later, on March 25 – just five days after his transfer from HMP Lincoln to Lowdham Grange.<\/p>\n While at Lincoln, he was placed on a suicide and self-harm warning; however, this was not picked up by reception staff at Lowdham Grange, as staff did not read his history.<\/p>\n He spoke little to no English, which meant he was prone to isolation.<\/p>\n The jury found that during the transfer period between Serco and Sodexo, confusion arose over which regime to follow, leaving numerous departments feeling overwhelmed.<\/p>\n Other issues mentioned included inadequate assessments, the sharing of risk-relevant information, and a shortage of experienced healthcare staff.<\/p>\n Coroner Laurinda Bower expressed her concerns in a PFD report sent to various agencies, including NHFT.<\/p>\n Kenneth Baylis<\/p>\n Kenneth Baylis<\/a> was granted unescorted leave by NHFT while a patient at Millbrook Mental Health Unit, and he stepped in front of a bus on January 23, 2023.<\/p>\n Coroner Elizabeth Didcock said, during an inquest held in January 2024, that Mr Baylis’s \u201creal and imminent\u201d suicide risk throughout his admission was not properly recognised by those who were supposed to care for him.<\/p>\n A number of failures were found during the inquest, including not involving Mr Baylis\u2019s family in risk assessment and support and safety planning, not following procedures for unescorted leave, and not taking into account the factors which contributed to suicidal risk.<\/p>\n Dr Didcock concluded that the trust\u2019s decision to allow unescorted leave on January 10, 2023, was not appropriate.<\/p>\n She said: \u201cAll these omissions in care made a more than minimal, negligible, or trivial contribution to [Mr Baylis\u2019s] death.\u201d<\/p>\n Mr Baylis, a retired personnel officer who lived in Mapperley <\/a>Park, began struggling with depression in 2021.<\/p>\n This was followed by four \u201cserious and escalating\u201d suicide attempts over a 14-month period leading up to his death.<\/p>\n Dr Didcock said: \u201cSadly, however, the building picture of increasing risk of suicide was not fully understood by the team on Kingsley ward.<\/p>\n \u201cDuring Mr Baylis\u2019s final inpatient psychiatric admission, the seriousness and his intent to die were significantly underestimated.<\/p>\n \u201cThere was inadequate risk assessment during this last admission, lacking in detail and incomplete.<\/p>\n \u201cHis repeated reporting of lack of suicidal thoughts and intentions was not adequately challenged.\u201d<\/p>\n Dr Didcock warned, at the time, that more deaths could occur if the trust didn\u2019t take action.<\/p>\n Trust Policies and procedures regarding family involvement in assessment of risk, care plans, and MDT meetings were not followed.<\/p>\n Alexander Lyalushko<\/p>\n Alexander Lyalushko<\/a> was a vulnerable young man who lived alone in the Gedling<\/a> borough.<\/p>\n He hanged himself in his home on January 2, 2023, after NHFT failed to act on a request from his GP.<\/p>\n Mr Lyalushko had been extensively involved with mental health services throughout his life, as he was diagnosed with a number of conditions, including autistic spectrum disorder, anxiety and depression.<\/p>\n He also expressed suicidal thoughts and had even made suicide attempts.<\/p>\n Between August 2015 and 2019, and from July 2020 to March 2022, Mr Lyalushko received care from the Gedling Local Mental Health Team under NHFT.<\/p>\n His GP made a request for involvement in November 2022 to the same service, but \u201cfor reasons which have not been ascertainable\u201d, no action was taken, coroner Amanda Bewley said following an inquest in March 2024.<\/p>\n About a month after the request was sent, Mr Lyalushko took his own life.<\/p>\n Miss Bewley explained in her PFD report that the trust conducted a serious incident review following the man\u2019s death, in which she identified \u201ca number of deficiencies\u201d.<\/p>\n These included the review not identifying the GP\u2019s request to NHFT in November 2022 had gone ignored, and not involving Mr Lyalushko\u2019s family in the process.<\/p>\n The coroner explained at the time that these failures added to the likelihood of future deaths occurring in similar circumstances.<\/p>\n Kaine Fletcher Kaine Fletcher was a dad-of-two(Image: Family handout)<\/p>\n Kaine Fletcher<\/a> was 26 years old when he died hours after being restrained by the police<\/a> during a mental health episode on July 3, 2022.<\/p>\n The father-of-two’s death was found to have been contributed to by a number of gross failings from East Midlands Ambulance Service<\/a> (EMAS), Nottinghamshire Police and NHFT.<\/p>\n Mr Fletcher, who was originally from Strelley but lived in Hucknall<\/a> at the time of his death, had been diagnosed with Paranoid Personality Disorder and also had a history of substance abuse, having been in rehab twice.<\/p>\n Officers arrived at Mr Fletcher’s mum’s address on the afternoon of July 2 after he made threats to kill, later requesting assistance from the Street Triage Team, a team formed through the collaboration of the police and NHFT.<\/p>\n The psychiatric nurse decided Mr Fletcher did not require an assessment under the Mental Health Act, and so the police didn’t detain him.<\/p>\n Officers were then called again at around 2am on July 3 and Mr Fletcher was found to be in an “agitated state” and “very paranoid”.<\/p>\n The father was restrained as a result, but there was “little management” of the incident by an experienced officer, and a jury concluded in July 2025 that Mr Fletcher’s increasing time in restraint and his resistance should have raised concerns.<\/p>\n EMAS<\/a> was eventually called to the scene, but no communication of the detention under the Mental Health Act or the use of restraints was mentioned.<\/p>\n Mr Fletcher eventually died following an unsurvivable cardiac arrest at Queen’s Medical Centre<\/a> (QMC<\/a>) due to the “physiological effects of exertion following a period of restraint”, combined with cocaine and other substances.<\/p>\n The jury concluded that Mr Fletcher was overlooked by agencies in the months prior to his death due to his drug use, and a lack of communication between them led to the father “being lost in the system with no effective or practical treatment available”.<\/p>\n Coroner Alexandra Pountney identified a number of concerns in her PFD report, including a gap in mental health services for those with a combined mental health condition and substance misuse diagnosis.<\/p>\n Dan Tucker Dan Tucker, 24, took his own life only two hours after his discharge from Highbury Hospital(Image: Mark Tucker)<\/p>\n![\"Woman](\"https:\/\/www.newsbeep.com\/uk\/wp-content\/uploads\/2026\/04\/2_1000007887.jpg\")
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