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
113 results
David Honnor
Partially Responded
2022-0267 30 Aug 2022 Dorset
Suicide
Concerns summary (AI summary) Public access to gas canisters used for self-harm is unrestricted, lacking licensing or clear colour coding for emergency identification, and safety information on labels is insufficient.
Noted (AI summary) The Health and Safety Executive explains the existing regulations around the purchase, licensing, and safety information for oxygen-free nitrogen products, stating that sector-specific legislation places obligations on actors within a supply chain to provide instructions and safety information that are clear, legible and in easily understandable English.
Jessica Laverack
All Responded
2022-0344 27 Jun 2022 East Riding and Hull
Alcohol, drug and medication related deaths Suicide
Concerns summary (AI summary) The report identifies a need for recognition of the link between domestic abuse and suicide, lack of systems to care for vulnerable individuals not meeting 'high risk' criteria, and a lack of information sharing between agencies.
Noted (AI summary) The Ministry of Justice is working with the Home Office to prioritise commitments in the Tackling Domestic Abuse Plan, including investing over £230 million in tackling domestic abuse. They have also worked to improve probation staff awareness of MARAC and published a draft Victims Bill. The Home Office acknowledges the report and states that officials will provide a full response by the stated deadline. The Home Office highlights the Domestic Abuse Act 2021, its statutory guidance published in July 2022, and the cross-Government Tackling Domestic Abuse Plan published in March. The plan includes funding, model policies, training and awareness packages. The Department of Health and Social Care is working with the Home Office on the Tackling Domestic Abuse Plan and will include measures to tackle domestic abuse in the national suicide prevention strategy. Integrated care boards are required to set out how they will address the needs of victims of abuse and NHS England is developing guidance to assist them.
Ketheeswaren Kunarathnam
All Responded
2022-0030 26 Jan 2022 West London
Mental Health related deaths Other related deaths State Custody related deaths
Concerns summary (AI summary) Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Action Taken (AI summary) The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by HMPPS for front-line immigration officers in prisons. They also highlight improvements to the Adults at Risk in Immigration Detention policy and the introduction of Detention Case Progress Panels.
James Lacey
Historic (No Identified Response)
2022-0073 29 Nov 2021 Lancashire & Blackburn with Darwen
Other related deaths Product related deaths Suicide
Concerns summary (AI summary) Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, posing a risk of misuse.
Berenice Bell
Partially Responded
2021-0404 22 Nov 2021 Inner North London
Mental Health related deaths Product related deaths Suicide
Concerns summary (AI summary) Websites promoting or assisting suicide are easily accessible, and platforms lack adequate independent scrutiny to remove age-inappropriate and harmful content.
Action Planned (AI summary) The Department is taking steps to protect users online via the draft Online Safety Bill, which will require in-scope companies to remove illegal content that encourages or incites suicide. They are also considering Law Commission recommendations for new offences to address encouragement or assistance of self-harm online.
Mustafa Abdelkarim
All Responded
2021-0393 19 Nov 2021 Gwent
Other related deaths Wales prevention of future deaths reports
Concerns summary (AI summary) Immigration Officers receive an introduction to pursuit policy but lack specific training in pursuit procedures and decision-making during stressful pursuit situations.
Action Planned (AI summary) Immigration Enforcement will revise training to provide greater focus on dynamic decision making, with mandatory training for officers delivered from April 2022. Pursuit policy will be incorporated into the operational assurance framework.
Fishmongers’ Hall Inquests
All Responded
2021-0362 3 Nov 2021 London City
Other related deaths Police related deaths State Custody related deaths
Concerns summary (AI summary) This document is a questionnaire for the jury, intended to determine the means and circumstances by which Jack Merritt and Saskia Jones died, focusing on identifying any errors, omissions, or circumstances that may have caused or contributed to their deaths.
Noted (AI summary) CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders. The Learning Together Network CIC states it cannot take steps on the recommendations as it did not employ staff or run partnerships, and will be dissolved in January 2022. The Office for Students will write to all registered higher education providers in England, making them aware of the report and asking them to consider changes to their approach to risk assessment of events, programmes, and information sharing. The College of Policing acknowledges the concerns raised and states its commitment to supporting other bodies in achieving improvements in terrorist offender management. They provide broader offender management training products and guidance and will work with partners to ensure they are updated. CTPHQ now has CT Nominal Management specialist trained officers who will attend all future CT MAPPA (Category 4) cases and are responsible for designing and delivering a risk management plan (RMP). West Midlands Police exceeds national guidance for visits to Registered Terrorist Offenders/Pathfinders and now feed this into the MAPPA panel. The government is legislating a new power of personal search through the Police, Crime, Sentencing and Courts Bill, allowing police to stop and search terrorist offenders on license under certain circumstances. The University of Cambridge has created a new policy and guidance for staff and students working with people who have offended, and the Institute of Criminology has developed a Risk Assessment Form for all activities. The University has also stopped delivering the Learning Together programme. MoJ accepted recommendations relating to the Fishmongers' Hall attack. A new framework is being designed for Learning Together activity in prisons. Statutory guidance on MAPPA meetings will be strengthened, and the Police, Crime, Sentencing and Courts Bill includes a power for police to search terrorist offenders on licence. The Secretary of State will engage with the higher education sector to encourage action to implement the recommendations and officials have spoken to the Office for Students to encourage them to take action. Officials have also engaged with HMPPS to design a new framework to define roles and responsibilities of prisons and higher education providers.
Hamish Howitt
All Responded
2021-0320 23 Sep 2021 West Sussex
Police related deaths
Concerns summary (AI summary) Police officers, lacking medical training, failed to ensure an injured, seemingly inebriated person was taken to hospital, leading to a missed traumatic brain injury. Training needs to mandate hospital referral for such individuals.
Action Planned (AI summary) Avon and Somerset Constabulary circulated a memorandum to all officers with guidance on head injury risk, sent guidance to first aid trainers, and added guidance to first aid training modules. They also incorporated training on head injury response into Taser, Public Safety, and Public Order training, all completed in October 2021. The Home Office has consulted with the College of Policing and NPCC, and the College will address the coroner's concerns about police first aid training through its formal governance routes. The College of Policing and NPCC will raise concerns about alcohol's impact and head injury assessment in first aid training at the next First Aid Forum meeting in December to assess feasibility of addressing them within the FALP licence scope. The College is also reviewing high-level learning outcomes within the FALP to emphasize life-saving elements, considering acute alcohol intoxication, intentional overdoses, and extending head injury learning to Module 2.
Emma Day
Partially Responded
2021-0263 3 Aug 2021 London Inner South
Other related deaths Police related deaths
Concerns summary (AI summary) The Gaia Centre did not record the details of protective orders, Lambeth Children’s Social Care lacked knowledge of the orders, and the Metropolitan Police Service's Merlin Report did not mention the Non-Molestation Order, highlighting a potential system failure regarding protective orders and information sharing; the Child Maintenance Service of Department of Work and Pensions also exhibited a system failure in handling reports of domestic violence.
Action Taken (AI summary) The Metropolitan Police Service now records non-molestation orders on both the Police National Computer (PNC) and Criminal Intelligence System (CRIMINT), ensuring they are identified during background checks in safeguarding incidents; also, a review of the Multi-Agency Safeguarding Hubs (MASH) was commenced in June 2021, to improve risk identification.
Henry Boddy
Partially Responded
2021-0227 2 Jul 2021 Inner London North
Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a fire load arising from hoarding behaviour.
Noted (AI summary) The Home Office acknowledges concerns about fire risks from hoarding but suggests a multi-agency approach is more appropriate than enforcement under the Fire Safety Order. They highlight the role of Safe and Well visits and safeguarding referrals.
Emiel Malinski
All Responded
2021-0198 10 Jun 2021 Manchester South
Other related deaths Product related deaths Suicide
Concerns summary (AI summary) Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Action Planned (AI summary) The Home Office is reviewing the firearms licensing exemption for miniature rifle ranges, prompted by the incident. They conducted a public consultation on tightening controls and will consider the responses before deciding on further measures.
Shane Gilmer
Historic (No Identified Response)
2021-0140 5 May 2021 County of the East Riding of Yorkshire and City of Kingston-Upon-Hull
Other related deaths Police related deaths Product related deaths
Concerns summary (AI summary) Crossbows lack essential regulation, including ownership records or licensing, unlike firearms. This absence of control over their circulation and storage, despite their lethal capabilities, poses a significant public safety risk.
Natasha Crabb
Partially Responded
2021-0103 13 Apr 2021 County of Surrey
Other related deaths
Concerns summary (AI summary) There are no legal powers to prevent butane inhalation or restrict its purchase, making it easy for individuals addicted to obtain large amounts despite fatal risks.
Action Planned (AI summary) The Department of Health and Social Care directs readers to the Talk to FRANK website, mentions contact with the Home Office re: powers under the Psychoactive Substances Act 2016, and plans to invest £2.5m in piloting an enhanced RECONNECT service for offenders with complex needs.
Joe Robinson
Partially Responded
2021-0074 15 Mar 2021 Greater Manchester South
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) Police were unable to prevent a large, illegal gathering with no safety provisions, and concerns remain about whether lessons learned regarding policing such events have been effectively shared.
Noted (AI summary) The Home Office acknowledges the concerns and outlines the police powers to deal with illegal raves, but states that decisions about deployment are operational matters for the police. They highlight funding to tackle drug supply, treatment services, and Project ADDER.
Claire Richards
Partially Responded
2020-0253 23 Nov 2020 County Durham and Darlington
Alcohol, drug and medication related deaths Mental Health related deaths
Concerns summary (AI summary) Illegally dealt prescription drugs are of increasing concern, and what steps are projected for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands?
Noted (AI summary) The Royal Pharmaceutical Society acknowledges the concerns regarding prescription medicine misuse and highlights their role in promoting best practices, noting that the General Pharmaceutical Council regulates pharmacy. They suggest Public Health England and the Advisory Council for the Misuse of Drugs should be aware of the report.
Imane Bouasbia
Partially Responded
2020-0234 12 Nov 2020 East London
Police related deaths Suicide
Concerns summary (AI summary) Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.
Action Taken (AI summary) The MPS emailed all SOIT officers and Public Protection Department managers with the instruction that SOIT and investigating officers must inform a supervising officer if they receive any contact from a victim that causes them concern. Continuous Professional Development events for SOIT officers will include suicide awareness and a contribution from Hostage and Crisis negotiator regarding how to more effectively engage with a person in a mental health crisis.
Chelsie Greatorex
All Responded
2021-0018 11 Nov 2020 East London
Alcohol, drug and medication related deaths Police related deaths
Concerns summary (AI summary) The police investigation into a child sexual assault lacked specialist officer involvement, experienced significant delays, and provided insufficient support to the complainant.
Action Planned (AI summary) The Home Office is conducting a review of the criminal justice response to rape, consulting on a new Victims’ Law, and investing in rape support centers and Independent Sexual Violence Advisers (ISVAs). The MPS is developing a Suicide Prevention Policy Document and Toolkit, including information on suicide prevention, support services, risk indicators, contacts and best practice, with a draft expected by the end of December 2020; they are also improving training and guidance for officers and staff, including an investigative standards document and meeting with other forces to share good practice.
Valdotas Gerbutavicius
Historic (No Identified Response)
2020-0184 25 Sep 2020 East London
Other related deaths
Concerns summary (AI summary) Inadequate legislation and a lack of internet sales prohibitions allow dangerous DNP 'diet pills' to remain readily available online, leading to numerous deaths among vulnerable people.
Thiago Araujo
Partially Responded
2021-0132 29 Jan 2020 East London
Community health care and emergency services related deaths Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths
Concerns summary (AI summary) The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Noted (AI summary) The Trust has implemented an additional recommendation that discharge of Crisis Team service users due to non-engagement must be discussed in a multidisciplinary meeting with senior overview, and clearly communicated to relevant parties. Legal advice has been sought and guidance circulated to staff regarding potentially dangerous packages. Royal Mail asserts that their processes for handling restricted and prohibited items are adequate and appropriate, given the legal restrictions on interfering with postal packets. They state that they do not intend to take any action in response to the report. The MPS is developing a Suicide Prevention Policy Document and Toolkit. An investigative standards document is also under development as guidance for police first responders. The Department of Health and Social Care describes actions taken to limit the availability of chemicals used in suicides, including working with a chemical supplier to identify suppliers on online retail platforms and noting eBay's global prohibition of the sale of the chemical. It also notes work with the media to improve suicide reporting and the publication of an Online Harms White Paper. The Home Office is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces including reporting suspicious transactions within 24 hours.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332 1 Nov 2019 London Inner (South)
Other related deaths
Concerns summary (AI summary) The coroner identified matters of concern which are being reported to the addressees, after taking into account submissions from the bereaved.
Noted (AI summary) The City of London Police (CoLP) are working with partner agencies to test interoperability of communications and enhance training scenarios, including a 7 day live trial in February 2020 to station staff in the MPS control room, with a review in Autumn 2020, and are engaging with the MPS in ICCS and CAD upgrade projects, planning an interim solution until upgrades are complete. The BVRLA has worked with the DfT and law enforcement to prevent the use of rental vehicles in terrorist attacks, providing training, guidance and engagement opportunities to members, and has included additional criteria within member audits from Jan 2020 to monitor awareness, training and compliance against the Rental Vehicle Security Scheme. The LAS is planning a live trial for seven days in February 2020, with LAS and LFB staff based in the MPS control room, and will analyze the outcome and consider a recommendation for approval by Autumn 2020; it is also working with its emergency service partners and increased visibility of the HART and TRU teams. The Home Office acknowledges the coroner's concerns and provides context, stating that the issues raised are technical and will be considered by the police in collaboration with the Emergency Services Network programme. It also mentions ongoing work led by the National Police Chiefs' Council. The MPS is trialing a "London Emergency Services Contact Centre" with representatives from the LFB and LAS deployed within the Specialist Operations Room, with a table top exercise followed by a real-life 7-day trial planned for early 2020.
Amir Siman-Tov
Historic (No Identified Response)
2019-0302 28 Aug 2019 London (West)
State Custody related deaths
Concerns summary (AI summary) Healthcare professionals in the immigration removal centre were unaware of or disengaged from essential ACDT documents, creating critical information gaps and putting detainees at risk.
Kay Martin
All Responded
2019-0262 27 Aug 2019 Sunderland
Other related deaths
Concerns summary (AI summary) A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at severe risk.
Action Taken (AI summary) The Home Office has coordinated the implementation of several actions, including the NPCC publishing operational guidance on domestic abuse and high harm cases. HMICFRS are also inspecting all forces on their use of pre-charge bail. The government also introduced the Domestic Abuse Bill.
Karen Burns
All Responded
2019-0273 12 Aug 2019 Birmingham and Solihull
Emergency services related deaths Suicide
Concerns summary (AI summary) Police resources are critically insufficient, leading to incorrect call grading and leaving numerous P2 and P3 calls unanswered due to high demand for priority incidents.
Action Planned (AI summary) West Midlands Police has reviewed its call handling procedures, including providing additional training, instituting a "Log Closure Doctrine", reducing the number of logs held by each dispatcher, changing the dispatch model and shift patterns. They are also developing a new Command and Control platform to support call handlers. The Home Office will ask officials to contact West Midlands Police to identify if any remedial or additional measures need to be put in place to ensure calls are handled appropriately. The Home Office states that public safety remains the government's number one priority and cites increased police funding and plans to increase officer numbers. West Midlands Police accepted that the 101 call was incorrectly graded and has discussed this with the staff member in question, and has promised additional training for all control room staff. They have also instituted a "Log Closure Doctrine", reduced the number of logs held by each dispatcher, changed the dispatch model and shift patterns, and are developing a new Command and Control platform.
Aram Mustafa
All Responded
2019-0508 19 Jun 2019 Birmingham and Solihull
Suicide
Concerns summary (AI summary) Critical details regarding urgent medical needs and safeguarding concerns were not sufficiently shared between immigration and accommodation providers. Furthermore, safeguarding matters were not logged when individuals were subject to deportation.
Action Planned (AI summary) G4S now alerts its subcontractor UHS immediately of safeguarding concerns raised in Service Commission Forms from UKVI so that such cases can be raised with the Senior Safeguarding working group. Significant improvements have been made in relation to such cases, in particular, with the information conveyed by UKVI to G4S/UHS. Urban Housing Services has reviewed procedures and interactions with other agencies, including flagging incomplete safeguarding information with UKVI and G4S, directly notifying hospital visits to Attwood Green Medical Centre, updating out-of-hours guidance, and recording additional information in staff handover books. The Home Office is reviewing processes to ensure sufficient information is provided on Service Commission Forms, balancing this with data protection requirements. The Home Office will also share learning from this incident widely.
Sophie Lyons
All Responded
2019-0206 19 Jun 2019 Manchester (South)
Road (Highways Safety) related deaths
Concerns summary (AI summary) Dangerous car cruising on public roads in Trafford Park presents an unaddressed public safety risk. Ineffective multi-agency efforts and a lack of a region-wide approach mean the problem is merely displaced rather than resolved.
Noted (AI summary) Greater Manchester Combined Authority outlines its functions and relationship to policing, noting that the Chief Constable has operational independence. It acknowledges the need for a coordinated approach to car cruising across Greater Manchester and notes that developments are in train. The Home Office highlights the establishment of a national practitioners group for car cruising leads and states the National Police Chiefs' Council have also agreed to discuss car cruising at the next Roads Policing Intelligence Forum. The Home Office will continue to work closely with the police to improve the response to illegal activity at these events.