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 results
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.
Branko Zdravkovic
All Responded
2019-0047 13 Feb 2019 Dorset
State Custody related deaths
Concerns summary (AI summary) Detainee healthcare staff were incorrectly advised to use ACDT procedures instead of statutory Rule 35(2) reports, and lacked a formal system to inform the Home Office, impeding Article 2 obligations.
Action Planned (AI summary) The Home Office will write to all parties in IRCs by the end of April 2019 to reiterate the requirements for sharing information on detainees being managed under ACDT procedures. They will use learning from the HMPPS pilot to improve suicide and self-harm prevention guidance and procedures.
Kurt Cochran; Leslie Rhodes; Aysha Frade; Andreea Cristea; PC Keith Palmer.
All Responded
2018-0304 19 Dec 2018 London Inner (West)
Other related deaths
Concerns summary (AI summary) A Prevention of Future Deaths report was issued to multiple authorities following the Westminster terror attack to address systemic issues related to such events.
Noted (AI summary) The Parliamentary Authorities confirm that they already plan to consider the automation of Carriage Gates and their general ease of use as part of the ongoing renewal project; and external reviewers have already been extensively involved in the New Palace Yard project, and will continue to be involved. The MPS will revise Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices; MPS is working with MO19 and the National Police Chief’s Council to provide additional training on de-escalation techniques; and the MPS will ensure that there is appropriate input from tactical advisers at challenge panels, and the newly appointed PaDP OFC Sergeant will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. The MCA states sufficient guidance already exists in the public domain for operating commercial vessels and leisure boats on navigable rivers and canals, referring to existing codes and training courses. The BVRLA has increased counter terrorism training and guidance made available to vehicle rental and leasing firms, and routinely shares data and intelligence with police and counter terrorist authorities. The Department for Transport launched its Rental Vehicle Security Scheme in December 2018. The Home Office states the government accepts the Chief Coroner's recommendations and has taken action. The Department for Transport (DfT) launched the Rental Vehicle Security Scheme (RVSS) on 6th December 2018, and an industry led Advisory Panel was launched in January to oversee the development of the scheme. The London Ambulance Service states that the Chief Coroner found no matters of concern regarding their actions, so they will not be taking any further action. TfL implemented internal changes in October 2017 to improve communication of security advice. TfL is currently reviewing the height of all its bridge parapets to identify those that are below 1m high, with high priority bridges expected to be completed by April 2019.
John Hill
All Responded
2018-0195 25 Jun 2018 Dorset
Suicide
Concerns summary (AI summary) Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.
Action Planned (AI summary) The Home Office will encourage "professional curiosity" through new accreditation standards for Firearms Enquiry Officers being developed by the College of Policing. They intend to consult on draft statutory guidance to the police on firearms licensing, inviting the police to consider any wider family members when they are likely to be relevant. Durham Constabulary outlines that the Home Office is preparing to go to public consultation on their guidance to forces on issuing firearms certificates later this year, and they will endeavour to include the lessons learned from Mr Hill's death, in particular, for FEO's to ensure that they examine the domestic and family circumstances of an applicant should this appear to be relevant under Section 27 of the Firearms Act 1968. CFOA has disseminated information about the dangers posed by emollient creams to all fire and rescue services through internal communications channels, and will promote safety warnings relating to these creams through their own safety campaign weeks and online/press channels.
Anna Phillips
All Responded
2017-0033 8 Feb 2017 Cornwall and Isles of Scilly
Community health care and emergency services related deaths Mental Health related deaths
Concerns summary (AI summary) The deceased obtained a dangerous, unlicensed weight loss drug (2,4 Dinitrophenol) online, which is known to cause fatalities.
Action Taken (AI summary) The National Food Crime Unit (NFCU) continues to prioritise tackling the illegal sale of DNP, sharing intelligence with Border Force, Royal Mail, and Post Office Investigations, and monitoring the internet for illegal sales. This data sharing led to an Operational Instruction being issued to all Border Force Officers and assisted inquiries into a DNP supplier who is being prosecuted.
Richard Walsh
All Responded
2016-0377 25 Oct 2016 London Inner (South)
State Custody related deaths Suicide
Concerns summary (AI summary) There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial information being lost as he moved through different services; there was a lack of a national process for sharing mental health assessment information.
Noted (AI summary) Virgin Care has implemented a process to ensure colleagues have completed ACCT awareness training and are aware of PSI 1700 upon starting at HMP High Down, with annual refresher training. An auditing process has also been implemented for Fitness for Segregation forms, carried out by Lead Nurses. The Department of Health has brought concerns regarding AMHP training to the attention of the HCPC, which sets criteria and approves training programs. Responsibility for AMHP training is due to become the responsibility of a new regulator; Social Work England, in 2018. The Health Care Professions Council (HCPC) states that its existing criteria for AMHP training programs are appropriate and that individuals completing training have acquired the necessary skills in carrying out mental health assessments. They suggest that issues are best addressed by Local Social Services Authorities through ongoing training. Hampshire County Council and Portsmouth City Council have taken several actions, including reviewing AMHP practices, providing additional training, commissioning audits, and reviewing policies. The HCPC reviewed documentation and closed the case, taking no further action regarding the AMHP's fitness to practice.
Alice Gross
All Responded
2016-0488 12 Jul 2016 London Inner (West)
Child Death Other related deaths
Concerns summary (AI summary) UK police lack mandatory foreign conviction checks for all arrestees and UK nationals. There are concerns about inadequate international data sharing, "watch list" management, and potential loss of Europol access post-Brexit.
Action Taken (AI summary) The Home Office details steps taken to improve checks for foreign convictions on arrest, including implementation of the European Criminal Record Information System (ECRIS) and increased use of Interpol I-24/7, and notes arrangements are in place at Border Force to identify individuals who pose a risk.
Steven Billington
All Responded
2016-0247 12 Jul 2016 Manchester (West)
Other related deaths
Concerns summary (AI summary) No specific concerns are detailed in the provided text.
Noted (AI summary) The Minister offers condolences to the family and friends of Mr. Billington. The Department acknowledges the report and notes that current guidance requires isolators for fire alarm systems to be secured against unauthorised tampering, and suggests the system in question may have been an older system. They suggest any weaknesses in standards be brought to the attention of the British Standards Institution.
Stephen Hunt
All Responded
2016-0216 8 Jun 2016 Manchester (City)
Community health care and emergency services related deaths Other related deaths
Concerns summary (AI summary) Fire and Rescue Services lacked adequate measures for managing heat stress in hot environments, had poor communication protocols, and insufficient training/SOPs for incident role handover, hazard recording, and thermal imaging camera use.
Noted (AI summary) DSFRS provides responses to the coroner's questions, but does not describe any specific actions taken or planned by their own service. The Ministry of Justice acknowledges the coroner's concerns regarding legal aid funding but states that funding decisions are made independently and there are no plans to change the current scheme.
Joyce Carney
All Responded
2016-0140 7 Apr 2016 Manchester West
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary) Fragmented risk assessments and a lack of communication between police and hospital staff led to a misunderstanding of the ward layout, inadequate patient supervision, and a failure to assess risks to other patients and staff. There were no agreed protocols or senior oversight.
Action Planned (AI summary) The Trust has been working with Greater Manchester Police to learn lessons and address concerns including the security of patients under arrest and the protection of other patients. A final draft of the 'Patient Under Escort Record' is to be agreed and training on its use will be rolled out. The Department of Health has shared a report with NHS Protect to support a joint DH Home Office initiative to develop protocols, policies and procedures, to provide a national framework for joint risk assessments between police and NHS staff for patients detained at a hospital under arrest. The Minister for Policing will write to the National Policing Lead for Custody, Chief Constable to raise the matter with Chief Constables across England and Wales. The College of Policing is leading a programme of work aiming to set a national framework clarifying the roles and responsibilities of health and policing partners to maintain safety in mental health settings.
Jacques Lakeman and Torin Lakeman
All Responded
2015-0191 15 May 2015 Manchester (West)
Alcohol, drug and medication related deaths
Concerns summary (AI summary) Easy access to anonymous 'Dark Web' sites for unregulated illicit drugs with unknown potency and content poses a significant and ongoing risk of future deaths.
Noted (AI summary) The Home Office acknowledges the concerns, describes actions taken by the NCA and Border Force to combat online drug supply, and states that law enforcement agencies have powers to act against suppliers, but does not commit to new actions.
Paul McGuigan
All Responded
2015-0185 12 May 2015 Manchester (South)
Other related deaths
Concerns summary (AI summary) General concerns were raised across relevant agencies about risks that could lead to future deaths, requiring action.
Action Planned (AI summary) The Home Office states that the Notifiable Occupations Scheme (NOS) was withdrawn and replaced with a new police-led scheme, the Common Law Police Disclosure (CLPD) scheme, which provides greater consistency across forces in the disclosure of information. GMP will train officers in understanding their responsibilities under the pressing social need test, including classroom and NCALT training. They will be entering and holding notifications on the intelligence file of offenders. The SIA offered training and guidance to all UK police forces. The Trust states that following the Bradley Report (2009), the MDO teams transferred into single line management and implemented operational policy and approved documentation for assessment of needs and risks. They are rolling out an electronic clinical record (PARIS) and clinical staff have adequate time to access information from case notes.
Jason Houghton
All Responded
2015-0127 30 Mar 2015 Manchester (West)
Product related deaths
Concerns summary (AI summary) The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of future deaths.
Action Taken (AI summary) The Home Office acknowledges concerns about online drug supply, notes ongoing efforts by law enforcement to close UK-based websites and work with international partners. Since the death, the MHRA closed down the website Wmedipk com.
David Giles
All Responded
2014-0321 9 Jul 2014 Birmingham & Solihull
Other related deaths
Concerns summary (AI summary) The coroner raises concerns about the unrestricted availability of helium gas canisters, their standard size and lack of modified control valves, and the ease of accessing information on suicide methods using helium gas online.
Noted (AI summary) The Department of Health acknowledges the concerns regarding the sale of helium gas and references a previous response to a similar case. They provide a copy of that earlier reply.
Mark Duggan
All Responded
2014-0182 29 May 2014 London (North)
Police related deaths
Concerns summary (AI summary) Insufficient intelligence gathering and a failure to exhaust all intelligence avenues regarding key individuals prior to the stop, impacting subsequent police actions.
Noted (AI summary) The IPCC acknowledges the coroner's concerns, particularly regarding access to intelligence materials, and states it is best placed to determine who within the IPCC investigation should have access. The IPCC considers that there should be a clear legal right of access by IPCC investigations to all relevant intelligence material. The Home Office acknowledges the concerns raised, particularly regarding the IPCC's resources at the scene and access to intelligence. The response explains the existing legal framework for investigations and information disclosure, highlighting the need to balance transparency with national security. The National Armed Policing Portfolio has commenced work to determine whether the introduction of body worn video (BWV), might be included in armed policing operations. The National Policing portfolios will ensure liaison with the College of Policing to incorporate, reiterate and reflect issues relating to cordon management and evidence preservation in its post incident management and operational training. The National Crime Agency notes the concerns raised and states it has undertaken a thorough internal review of its operating procedures regarding intelligence gathering, development, and dissemination. Following this review, the Agency believes that no more could have realistically been done to avoid the incident. The MPS will adopt a procedure for all future police shootings whereby a Garage Sergeant or Collision Investigator is called by the DPS to download the IDR at the scene, which will then be available to police; the IPCC and any subsequent legal proceedings
Jason Nock
All Responded
2014-0013 13 Jan 2014 Black Country
Alcohol, drug and medication related deaths
Concerns summary (AI summary) An entirely unregulated product is readily available without consumer information on safe dosage or potential consequences, leaving users unaware of the substance they are consuming.
Action Planned (AI summary) The Home Office has asked the Advisory Council on the Misuse of Drugs (ACMD) for advice on AH-7921 and is collecting evidence from health organizations and law enforcement. They are also undertaking a review of the UK's response to new psychoactive substances.