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.

Response Status (last 2 years, 30 reports)
Responded 25 No Response 3
AI Classification
Action Taken 36%
Action Planned 33%
Noted 30%
Disputed 0%
Based on 275 classified responses
PFD Reports Received by Quarter
PFD Reports
113 results
Kesia Leatherbarrow
Partially Responded
2015-0143 16 Apr 2015 Manchester (South)
Child Death Other related deaths
Concerns summary (AI summary) Critical communication failures and incomplete information sharing between Children's Services and CAMHS across different regions, along with a failure to transfer the Youth Offending Team case, led to a lack of support for a high-risk young person.
Action Planned (AI summary) The Department of Health has shared the report with NHS England, who are working to develop Liaison and Diversion services in Greater Manchester. NHS England is also reshaping mental health services commissioning and delivery and will prioritize investment in areas with Local Transformation Plans. The government has already made a partial change to PACE via the Criminal Justice and Courts Act to require 17 year olds to be treated as 10-16 year olds for detention after charge. Planning is underway to amend the remaining PACE provisions, and the Secretary of State for Education wrote to local authorities reminding them of their duty to provide accommodation for children denied bail. A multi-agency working group has been commissioned to understand issues and develop solutions. The CPS has modified CPS training so advocates conducting youth court cases are reminded that a youth can always be remanded for their "own welfare". The Chief Crown Prosecutor for Greater Manchester is discussing wider issues and lessons learned with the Assistant Chief Constable for GMP. Pennine Care NHS Foundation Trust has completed an investigation, requesting written clinical summaries and risk assessments when young people transfer from other mental health services. The health diversion pathway has been re-published and re-promoted, and a multi-agency panel now has the capacity to deal with children and young people.
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.
Harold Ambrose
Historic (No Identified Response)
2015-0118 25 Mar 2015 Essex
Other related deaths
Concerns summary (AI summary) There is no requirement for GPs or Mental Health Trusts to notify police about mental health concerns for firearm licence holders, and licence information was not properly flagged in medical records.
Anne Fowler
Historic (No Identified Response)
2015-0104 19 Mar 2015 Black Country
Other related deaths
Concerns summary (AI summary) Smoke alarm covers were left in place after installation, making them inaccessible and ineffective. Legislation should require their removal by builders or landlords prior to occupation.
Maria Stubbings
Historic (No Identified Response)
2014-0458 23 Oct 2014 Essex
Other related deaths
Concerns summary (AI summary) Gaps in the system allow individuals convicted of murder abroad to enter the UK without conditions or local police notification, lacking retrospective data sharing, passport warnings, or local police alerts.
Matthew Flatman
Historic (No Identified Response)
2014-0429 6 Oct 2014 Portsmouth & South East Hampshire
Alcohol, drug and medication related deaths
Concerns summary (AI summary) The slow process of proscribing the "legal high" MDAI/Gogaine poses a fatal risk, particularly to users with cardiac problems, requiring accelerated action.
Brian Dalrymple
Partially Responded
2014-0410 18 Sep 2014 West London
Other related deaths
Concerns summary (AI summary) The report identifies a lack of awareness among detention staff regarding indicators of mental health issues, a failure to act on recorded observations, inadequate medical visits to segregated detainees, and the absence of a comprehensive clinical record system.
Noted (AI summary) GEO Group states that as the contract for Harmondsworth IRC passed to Mitie, they cannot take action regarding working practices there. However, they will consider lessons learned from the inquest for their other operations.
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.
Hywel Hughes
Partially Responded
2014-0311 2 Jul 2014 North West Wales
Police related deaths
Concerns summary (AI summary) Police training on positional asphyxia is inadequate, and vehicle designs hinder monitoring detainees. The SIA also fails to review restraint-related deaths by door supervisors.
Action Taken (AI summary) North Wales Police amended their training materials on positional asphyxia to include snoring as a symptom and added an exercise to demonstrate the dangers of medical emergencies. They also designed and are testing a single cell compartment bubble car and considering auditory improvements.
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
Christopher Shapley
Historic (No Identified Response)
2014-0121 11 Mar 2014 Cardiff & the Vale of Glamorgan
State Custody related deaths
Concerns summary (AI summary) Critical medical and self-harm risk information from police custody failed to transfer securely to the prison via the PER form, leading to inadequate assessment and observation of the prisoner.
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.
Andrew Cairns, Rachael Slack and Auden Slack
Historic (No Identified Response)
2013-0290 1 Nov 2013 Derby and Derbyshire
Other related deaths
Concerns summary (AI summary) Police failed to inform the Mental Health Team of an arrest for threats to kill despite knowing of a recent mental health assessment; an existing information-sharing policy was also undisclosed.