Home Office
PFD Addressee
Reports: 113
Earliest: Nov 2013
Latest: 24 Mar 2026
83% 2-year response rate (matches average). 36% of classified responses show concrete action taken.
PFD Reports
67 resultsSamuel Dickinson
All Responded
2026-0082
10 Feb 2026
Manchester West
Other related deaths
Concerns summary (AI summary)
Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant issues to police.
Noted
(AI summary)
• A new Statutory Instrument will add a new condition to firearms and shotgun licences to require the holder to inform the police if they begin to suffer from a new relevant medical condition, or if an existing condition significantly worsens, during the lifetime of the licence.
• A new licensing condition will require the licence holder to inform the police if they consult a third-party medical practitioner who is not their GP.
Alexander Lewis
All Responded
2025-0539
24 Oct 2025
Swansea Neath & Port Talbot
Road (Highways Safety) related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
Pursuing drivers lacked the ability to communicate dynamic risk assessments, were overburdened with tasks leading to missed critical information, and police training suggested a two-officer crew for safety.
Noted
(AI summary)
The Department of Transport notes that there are no specific statutory guidance or mandatory distance regulations for yellow lines near junctions. The decision rests with the local authority, and traffic signing is devolved to the Welsh Government. The Minister explains police driver training standards, noting that decisions on crewing are operational matters for Chief Constables. Pursuits resulting in a fatality are referred to the Independent Office for Police Conduct. South Wales Police acknowledges the concerns about crewing of Road Policing Unit officers during pursuits, but states its training and operational model are designed to ensure public safety and officer competence. They highlight national standards, training, and post-pursuit review processes, while also emphasizing the need to balance operational effectiveness and resource availability, deeming single crewing the most practical option.
Stella LeClaire
All Responded
2025-0619
9 Oct 2025
Northamptonshire
Suicide
Concerns summary (AI summary)
The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.
1 response
from Department of Health and Social Care
Georgia Barter
All Responded
2025-0491
2 Oct 2025
East London
Community health care and emergency services related deaths
Concerns summary (AI summary)
Frontline police officers face difficulty accessing the Police National Database for domestic abuse history across different force areas, hindering proactive identification and intervention for victims.
Noted
(AI summary)
The Home Office describes the Police National Database and its use, noting it is a top priority to tackle violence against women and girls and highlighting the new National Policing Centre for VAWG and Public Protection.
Leonardo Machado
All Responded
2025-0476
18 Sep 2025
Dorset
Road (Highways Safety) related deaths
Concerns summary (AI summary)
A lack of oversight regarding the 'rental' of food delivery licenses to children under 18 places them in vulnerable lone-working situations, increasing their risk of road traffic collisions and harm.
Noted
(AI summary)
Uber Eats uses industry-leading account-sharing detection technology, including real-time identity verification software requiring couriers to take selfies that are compared with their profile photo and monitors for suspicious behaviors that may indicate attempts to circumvent their security controls. Deliveroo has strengthened checks and processes to ensure rider accounts are only used by authorized individuals, including biometric checks and identity verification, and has a dedicated team investigating potential account sharing with minors; they also terminate agreements with riders who allow unregistered substitutes to use their accounts. Just Eat has introduced enhanced checks to ensure substitutes meet requirements set for all couriers, requiring pre-registration, biometric checks, and document submission to prove age and right to work; random biometric screening checks are also performed. HSE acknowledges concerns about rental of permits, employment of minors and lone working, but notes that road traffic accidents are generally a police matter. They highlight existing guidance and legislation, and ongoing work between government and the food delivery industry to improve security checks.
Gemma Weeks
All Responded
2025-0428
19 Aug 2025
Dorset
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Public and young people lack understanding of ketamine's severe dangers, exacerbated by its Class B classification suggesting lower risk, leading to increased usage, addiction, and devastating health complications.
Action Planned
(AI summary)
The Department of Health and Social Care is increasing the number of drug treatment places and providing targeted grants to improve drug and alcohol services. They are also launching a national media campaign focusing on the harms caused by ketamine. The Department for Education is piloting a teacher training grant, starting early 2026 and the Oak National Academy is developing new RSHE resources to support schools with the delivery of the updated RSHE curriculum, available from autumn 2025. The Home Office has requested an updated harms assessment of ketamine from the ACMD, including advice on whether it should be moved to Class A, and expects to receive the report by the end of 2025.
Jairus Earl
All Responded
2025-0349
10 Jul 2025
Dorset
Child Death
Suicide
Concerns summary (AI summary)
Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a risk of future deaths.
Action Planned
(AI summary)
The NPCC highlights the importance of personal responsibility on license holders for the security of firearms. The NPCC commenced delivery of an additional two-day course for Firearms Licensing Enquiry Officers focusing on domestic abuse, family turmoil, mental health and wellbeing in June 2025. The Home Office alerted all police forces to the issue of information sharing regarding shotgun license holders, and it is possible for police to check if an individual is a firearm or shotgun certificate holder. They will also engage with the DHSC directly regarding police access to health information. The Department will explore broadening access to relevant medical information of others residing at licence-holders' addresses and engage with GP representatives. They will work with them to ensure that operational guidance relating to the existing Digital Firearms Marker policy remains fit for purpose and considers ongoing learnings.
Andrew Kenward
All Responded
2025-0346
9 Jul 2025
Surrey
Alcohol, drug and medication related deaths
Suicide
Concerns summary (AI summary)
There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or consideration for dilution, posing significant risk.
Noted
(AI summary)
The Home Office is researching the availability of the substance in question and supports the DHSC in delivering the Suicide Prevention Strategy for England. Border Force has issued guidance to officers about control actions regarding goods at the border that may assist with suicide. The Department of Health and Social Care acknowledges the concerns regarding the purchase of sodium nitrite but states that the responsibility for these concerns sits within another organization.
Peter Ramsden
All Responded
2025-0467
8 Jul 2025
City of Kingston Upon Hull and the County of the East Riding of Yorkshire
Other related deaths
Concerns summary (AI summary)
A legal lacuna prevents police, paramedics, or fire services from forcing entry for welfare checks if a medical problem is suspected, hindering prompt, potentially life-saving treatment for incapacitated individuals.
Action Planned
(AI summary)
The NFCC is working with Humberside Fire and Rescue Service to share learning from the incident via the NFCC Organisational Learning platform. The letter also states that the Secretary of State at the Department of Health and Social Care (DHSC) will be made aware of comments concerning rights of access for ambulance personnel. The National Police Chiefs Council has established a group to review and track coroner’s reports relating to the application of Right Care, Right Person, and any learning will be disseminated and policy amended as needed.
Andrew Brown
All Responded
2025-0258
23 May 2025
Manchester West
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office is working with other departments to address concerns around the sale of harmful substances and online suicide content, including supporting the Online Safety Act and Ofcom's enforcement efforts.
Chantelle Williams
All Responded
2025-0255
23 May 2025
Manchester West
Alcohol, drug and medication related deaths
Mental Health related deaths
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Mathew Price
All Responded
2025-0254
23 May 2025
Manchester West
Alcohol, drug and medication related deaths
Suicide
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Shaun Bass
All Responded
2025-0253
23 May 2025
Manchester West
Alcohol, drug and medication related deaths
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Samuel Dickenson
All Responded
2025-0252
23 May 2025
Manchester West
Alcohol, drug and medication related deaths
Suicide
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's Suicide Prevention Strategy and is working with DSIT and Ofcom to address online suicide forums, with the Online Safety Act amended to make encouraging self-harm a priority offence.
Matthew O’Reilly
All Responded
2025-0251
23 May 2025
Manchester West
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Home Office guidance for selling reportable poisons fails to adequately advise online sellers on identifying purchases for self-harm, leading vendors to unknowingly facilitate suicides. Additionally, dangerous websites promoting suicide methods and poison sourcing are readily accessible.
Action Taken
(AI summary)
The Home Office supports the DHSC's cross-Government Suicide Prevention Strategy (2023-2028) and the DHSC's Concerning Methods Working Group; DSIT has amended the Online Safety Act to make encouraging self-harm a priority offence.
Joshua Leatham-Prosser
All Responded
2025-0110
27 Feb 2025
Dorset
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), trapping users in a cycle of dependence.
Noted
(AI summary)
The Home Office acknowledges the concerns about ketamine's classification and potential harm, notes that it will continue to work with partners to discourage misuse and alert people about the dangers of ketamine, and has commissioned the ACMD to provide an updated harms assessment of ketamine.
Champagauri and Dipak Bhatt
All Responded
2024-0677
6 Dec 2024
North London
Product related deaths
Concerns summary (AI summary)
Fires are caused by moisture ingress into condensate pumps. There's inadequate data sharing and analysis for white goods fires, poor manufacturing standards for components, and inconsistent risk assessment methodology.
Noted
(AI summary)
Hotpoint states it will support the LFB/AMDEA initiative of digital identification and comply with any future industry-wide regulatory requirements. It will also work with government policy makers, regulators, fire services, manufacturers and other stakeholders to continue to raise the bar for appliance product safety in the UK. BSI acknowledges the coroner's concerns and explains its role in standardization. The CPL/61 committee considered the request to improve standards for condensate pumps and filters but needs more information regarding the fire investigation before a decision can be made. AMDEA acknowledges the coroner's concerns and states its commitment to collaborating with stakeholders to enhance product safety. They also note that fire incident data for key appliances is collated annually to identify trends and inform safety improvements. North Yorkshire Council, as primary authority for Hotpoint, states that testing was conducted on the part in question and that it passed all tests. They have arranged for further testing and state Hotpoint will comply with any changes in the law. OPSS is seeking an update from BSI on the progress of a pilot project trialing a fire-resistant marking approach to enable identification of fire-damaged appliances and supporting their traceability. The National Fire Chiefs Council states that receiving information from manufacturers on replaced or recalled parts is not within their remit. They support the single recall register and advocate for manufacturers to share risk assessments when patterns of faults are found. The Home Office acknowledges the report but states it cannot provide a specific response due to a lack of detail regarding which aspects of information management need to change. CTSI acknowledges the coroner's concerns and describes its role in consumer protection and its support for OPSS. It highlights the need for a national approach to product safety and consumer reporting mechanisms.
Hannah Aitken
All Responded
2024-0622
14 Nov 2024
Surrey
Alcohol, drug and medication related deaths
Suicide
Concerns summary (AI summary)
The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import and availability of substances used for poisoning, despite known risks.
Action Planned
(AI summary)
DHSC is working with the Home Office and other stakeholders to consider potential regulation of a concerning substance. They are also working with the National Police Chiefs’ Council to bring together local intelligence to obtain near to real-time data from across the country on deaths by suspected suicide by method. The Home Office is working with the Department for Health and Social Care to consider the potential benefits and proportionality of further regulation regarding the substance in question. Border Force will continue to monitor its policies and explore opportunities to improve its ability to take action in line with existing legal provisions.
James Boland
All Responded
2024-0599
5 Nov 2024
Manchester South
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Ketamine's Class B classification falsely portrays it as safer than Class A drugs, encouraging illicit use despite causing severe, life-changing health problems like urological and liver damage.
Action Planned
(AI summary)
The Home Office acknowledges concerns about ketamine's classification and will commission the Advisory Council on the Misuse of Drugs (ACMD) to conduct an updated harms assessment of ketamine.
Frank Ospina
All Responded
2025-0338
25 Oct 2024
West London
State Custody related deaths
Concerns summary (AI summary)
Mismatched healthcare and Home Office interpretations of Rule 35 led to a failure in reporting suicidal intentions, and an inappropriate "closed" visit denied a detainee physical contact and private conversation with family.
Action Planned
(AI summary)
NHS England plans to revise Detention Services Order 09/2016, Rule 35 assessments towards a multidisciplinary approach to safeguarding and vulnerability management in Immigration Removal Centres, and will jointly develop a stakeholder engagement session with the Home Office to share the revised requirements with IRC providers and operators. The Home Office is developing an interim update to its Rule 35 guidance, strengthening monitoring in detention, and implementing a 'Prevention of future deaths in immigration detention strategy'. Progress will be reported through the MBDC governance structures. Mitie Care and Custody has implemented a revised Standard Operating Procedure to prevent "closed visits" and has introduced a website translation and accessibility service called 'Recite' across its immigration removal centres.
Natasha Johnston
All Responded
2024-0587
25 Oct 2024
Surrey
Accident at Work and Health and Safety related deaths
Other related deaths
Concerns summary (AI summary)
The absence of regulation on the number and weight of dogs an individual can walk in public creates significant safety risks for both dog walkers and other members of the public.
Action Planned
(AI summary)
DEFRA will engage with local authorities, the police and animal welfare stakeholders to gather evidence on the use of existing powers to implement controls on dog walking at a local level to review the effectiveness of the existing regime and the need for any further national measures. Surrey County Council implemented a 'Dog Walking Code of Conduct' in response to the incident, sends regular newsletters promoting good practices, and uses 'ambassadors' to champion responsible dog walking.
Sean Heath
All Responded
2024-0524
2 Oct 2024
Manchester South
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Noted
(AI summary)
NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.
Emma, Ellette and George Pattison
All Responded
2024-0438
8 Aug 2024
Surrey
Other related deaths
Suicide
Concerns summary (AI summary)
The process for obtaining shotgun certificates is flawed, as online doctors enable applicants to hide relevant medical history. Licensing authorities also lack methods to fully uncover coercive controlling behaviour.
Action Planned
(AI summary)
DHSC describes the rollout of a system by May 2023 to alert GPs when a patient with a shotgun certificate experiences a relevant medical condition, enabling them to flag it to the police. National FEO training will encourage positive engagement with the applicant and their family to ascertain their “domestic health and wellbeing”, and revised guidance may require interviews and engagement with families; the police are also looking to introduce the right to draw adverse inference if an applicant is evasive about family/previous partners. Surrey Police has revised its practice so FEOs now ask about the use of other medical services during visits to elicit information from applicants, and notes a national initiative to rewrite questions to be more explicit. The Home Office plans to issue a refreshed version of the Statutory Guidance early in 2025, which will include additional guidance for the police to help ensure that perpetrators of domestic abuse, coercive or controlling behaviour do not have access to firearms. The GPC will update its guidance to GPs to highlight the potential information gap in firearms licensing if external prescribers don't share relevant information or patients withhold it.
Zara Aleena
All Responded
2024-0409
26 Jul 2024
East London
Other related deaths
Concerns summary (AI summary)
Severe understaffing within the probation service led to poor quality risk assessments, inadequate staff training, and ineffective risk management. Additionally, the existing risk assessment tool and alert systems proved to be unwieldy and ineffective.
Action Planned
(AI summary)
London Borough of Redbridge details existing CCTV operator training which includes modules on behavioural body language training designed to detect suspicious behaviours. They also describe how they ensure risks for lone females are considered when planning events. The Metropolitan Police Service acknowledges the reviews lacked rigor. To address this, they will implement recommendations from an independent review, introduce body-worn video, review the integrated offender management system and implement Proactive Management Plans and have developed a new process map for clarity around recalls to prison. The Home Office acknowledges the concerns and will consider how to encourage business owners and staff to report predatory behavior. They mention plans to target perpetrators and address the causes of abuse and violence. HMPPS and MoJ acknowledge staffing issues and communication failures, but highlight the Prioritisation Framework implemented in January 2022. They also mention the Integrated Offender Management (IOM) guidance update (V4.1) from August 30, 2024, which explicitly requires POMs to be invited to all multiagency case conferences to improve communication.
Tcherno Bari
All Responded
2024-0296
3 Jun 2024
Birmingham and Solihull
Suicide
Concerns summary (AI summary)
Significant failures in multi-agency coordination and policy application for high-risk missing mental health patients were identified, including poor information sharing, lack of staff awareness regarding procedures, and ineffective challenge processes between mental health services and police.
Noted
(AI summary)
West Midlands Police (WMP) has provided additional RCRP training to call handlers and officers and produced an exhibit detailing the escalation point of contact for partner agencies to West Midlands Police. WMP has also emphasised the need for officers to gather information from all sources and record the rationale for decisions made, particularly regarding vulnerable people. NHS England will issue guidance to health systems on reviewing Serious Incident investigations to ensure lessons are learned and changes agreed upon. A national oversight group has been set up to review concerns and issues with RCRP, and this group feeds into a ministerial working group. This is an appendix to the BSMHFT response, specifically the Trust's Missing Patient Policy. It outlines the actions to be taken when a patient is missing or AWOL, relating to Informal inpatients, Detained patients who are AWOL and patients in the community, read in line with National Partnership Agreement: Right Care, Right Person (RCRP). The National Police Chiefs' Council clarifies the aims of Right Care Right Person (RCRP) and states that it appears the situation concerning Mr. Bari was treated as a missing person case from the outset by West Midlands Police, and therefore RCRP principles would not apply. BSMHFT has updated their Missing Persons Policy in line with Right Care Right Person (RCRP) changes, incorporating feedback from the inquest, and a new Executive Director of Quality and Safety/Chief Nursing Officer will be accountable for the policy. The updated policy includes a revised Appendix C form focusing on the reasoning for critical concern and requires formal notification from the police with their decision and reasoning if they have decided not to deploy immediately. The APCC provides background on its role and the role of PCCs in local policing, noting that it has developed guidance for members on the Right Care, Right Person approach. It states that the NPCC is reviewing the report to identify relevant national learning. The Department of Health and Social Care acknowledges the concerns raised, noting that local policies should align with the Mental Health Act Code of Practice and that local partners should reassess joint processes on risk assessment, communication, and escalation. They emphasise the importance of collaboration between policing and health partners. The College of Policing is undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. They are also working to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. The Home Office outlines the rationale and purpose of the National Partnership Agreement (NPA) and notes that decisions on implementation of Right Care Right Person (RCRP) are for individual Chief Constables. They state that missing persons cases are outside the scope of RCRP and existing police procedures should continue to operate.