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 resultsTarek Chowdhury
Historic (No Identified Response)
2019-0131
2 Apr 2019
London (West)
Hospital Death (Clinical Procedures and medical management) related deaths
State Custody related deaths
Concerns summary (AI summary)
There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.
Donna Williamson
Partially Responded
2019-0111
27 Mar 2019
London Inner (South)
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
The report identifies failures in repairing and securing a door, informing the victim of the suspect's release on bail, and the MARAC process's inability to protect chaotic, non-engaging individuals, alongside concerns about GPs' knowledge of disclosing confidential information.
Noted
(AI summary)
The Royal College of General Practitioners highlights existing guidance on information sharing and safeguarding, and the LGA has highlighted the importance of learning from Domestic Homicide Reviews at a national level. The LGA is seeking further information on the legal duty to repair doors of private rented accommodation.
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.
Dane Pearson
Partially Responded
2019-0056
14 Jan 2019
Manchester (South)
Mental Health related deaths
Suicide
Concerns summary (AI summary)
Police issued a CAWN without proper evidence, rationale, or risk assessment for a vulnerable person, and failed to communicate the decision to drop the investigation.
Action Planned
(AI summary)
The College of Policing is updating APP on issuing CAWNs to include a risk assessment and link to existing suicide prevention guidance. Additionally, GMP has implemented activities including providing districts with information, revising the bail and RUI policy, briefing front line officers, introducing trackers and dip sampling records.
Michal Netyks
Partially Responded
2018-0393
19 Dec 2018
Liverpool & Wirral
State Custody related deaths
Concerns summary (AI summary)
Prison Custody Officers lack training for delivering deportation papers, and foreign national prisoners have unequal access to legal advice. Mezzanine safety at HMP Altcourse and the Home Office's conduct during proceedings were also concerns.
Action Taken
(AI summary)
HMP Altcourse has updated NOMIS with a record of risk assessment conversations and issued a notice to staff reminding them to use the Big Word translation service. The MoJ Estates Directorate has agreed to carry out a review of balcony design, expected to be completed in the autumn.
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 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 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 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. 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. 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.
Jacqueline Oakes
Partially Responded
2018-0419
16 Oct 2018
Birmingham and Solihull
Other related deaths
Concerns summary (AI summary)
There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, preventing effective risk management.
Noted
(AI summary)
HM Prison and Probation Service describes existing arrangements for sharing risk information with partner agencies when a high-risk offender is released, including MAPPA and MASH. Guidance on activity required at the termination of sentence is currently being written.
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.
Kevin Freely
Historic (No Identified Response)
2018-0180
7 Jun 2018
London (West)
Community health care and emergency services related deaths
Concerns summary (AI summary)
Insufficient awareness and adherence to fire safety warnings regarding paraffin-based emollients, smoking in bed, and air-flow mattresses, combined with inadequate risk assessments, pose significant fire risks.
Stephen Shaylor
Partially Responded
2017-0380
18 Dec 2017
Exeter and Greater Devon
State Custody related deaths
Concerns summary (AI summary)
Prison healthcare for detox inmates was "not fit for purpose" due to insufficient stabilisation places and inadequate night welfare checks. Intermittent observations are insufficient to detect self-harm, requiring continuous monitoring.
Noted
(AI summary)
Care UK clarified that night welfare checks are conducted by HCAs, with a nurse available for assistance, and that the nurse from the Integrated Substance Misuse Service reviews the welfare check list daily; they reiterate that ACCT documentation is the responsibility of prison staff and the welfare checks don't replace it, and that the MPCCC clinic is held weekly.
Jane Powell
Partially Responded
2017-0310
30 Oct 2017
Manchester (North)
Other related deaths
Concerns summary (AI summary)
The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.
Noted
(AI summary)
The Department of Health provides background on regulations and describes Operation Pangea and the FakeMeds campaign; MHRA will investigate further once it receives information from Greater Manchester Police.
Jonathan Palmer
Partially Responded
2017-0173
31 May 2017
London Inner (West)
State Custody related deaths
Concerns summary (AI summary)
There was no effective system for families to provide crucial health information for prisoners, nor assurance of its dissemination. Ineffective control of contraband (Spice) inflow posed significant health risks within the prison.
Action Taken
(AI summary)
A Safer Custody Learning Bulletin has been issued regarding receiving emergency calls and sharing risk information from families, Samaritans, and others. HMP Wandsworth conducts searches of all visitors and prisoners after visits and uses various methods for prisoner searches, including a new body scanner. Mail and property are searched, and a policy on property was updated in 2016.
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.
Daniel Paylor
Historic (No Identified Response)
2016-0353
1 Jul 2016
Wiltshire and Swindon
Community health care and emergency services related deaths
Product related deaths
Concerns summary (AI summary)
Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.
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.
Arenijus Nedzelskies
Partially Responded
2016-0010
13 Jan 2016
South Lincolnshire
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.
Action Taken
(AI summary)
The Home Office highlights that the Psychoactive Substances Act 2016 restricts the production, supply and importation of psychoactive substances, and notes over 500 new drugs have already been banned. It also mentions toolkits and clinical guidelines for psychoactive substance use.
Catherine Findlay
Partially Responded
2015-0372
13 Oct 2015
Manchester (West)
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Concerns about the availability and misuse of dangerous "research chemicals" like MXP, which are freely marketed online, consumed, and pose a life-threatening risk.
Action Taken
(AI summary)
The Minister notes the concern about MXP and refers to the Psychoactive Substances Bill creating a blanket ban on the supply of NPS. The government has launched a toolkit to help local areas prevent and respond to the use of NPS and published clinical guidelines to aid in the detection, assessment and management of NPS users.
Rubel Ahmed
Partially Responded
2015-0308
5 Aug 2015
Lincolnshire (Central)
State Custody related deaths
Concerns summary (AI summary)
Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.
Noted
(AI summary)
The Home Office acknowledges the concerns regarding the death at Morton Hall IRC. They explain the challenges of unlocking rooms overnight, the existing practices for detention awareness, and the use of electrical items, but offer no concrete action.
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. 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. 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.
Anthony Garrett
Historic (No Identified Response)
2015-0153
21 Apr 2015
Manchester (West)
Alcohol, drug and medication related deaths
Concerns summary (AI summary)
Readily available and misused synthetic cannabinoids, despite warnings, are dangerous and caused a fatal cardiac event. Concerns were raised about their legal status and control.