Alcohol, drug and medication related deaths

PFD Category

Reports: 548 Areas: 67 Earliest: Sep 2013 Latest: 16 Mar 2026

81% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 36% from 58 (2023) to 79 (2024).

Responded 444 No Response 6 Historic 75 Pending 14

Action Taken 55%

Action Planned 25%

Noted 12%

Disputed 7%

Based on 354 classified responses

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PFD Reports

371 results

Matthew Faulkner

2018-0097 29 Mar 2018 Hertfordshire

East of England Ambulance Service Luton and Dunstable Hospital Princess Alexander Hospital

Concerns summary Emergency ambulance services face severe resource shortages, unsustainable demand, and significant hospital handover delays, reducing ambulance availability for emergency calls.

Bethany Shipsey

2018-0049 15 Feb 2018 Worcestershire

Department for Health

Concerns summary The highly toxic and antidote-less drug DNP is readily available online and popular as a 'diet drug.' There is a lack of legislation making its possession or supply illegal.

Vadims Aleksejevs

2017-0065 3 Mar 2017 Northamptonshire

Northampton County Council

Concerns summary There is a lack of clarity on whether adult social care or addiction services provide outreach to vulnerable homeless individuals on campsites, and an unclear statutory duty to house them.

Rachel Edwards

2024-0220 27 Feb 2017 Suffolk

Norfolk and Suffolk NHS Foundation Trust

Concerns summary The report describes the circumstances of a death from overdose but does not detail specific coroner's concerns regarding systemic failures or future death risks.

Raymond Woodward

2016-wp25391 26 Aug 2016 Birmingham and Solihull

Medicines and Healthcare Products Regul…

Christine Stevenson

2016-0123 10 Mar 2016 Manchester (South)

Medicines and Healthcare Products Regul…

Concerns summary Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially fatal risk to naive users due to the high total dosage.

Kevin Forster

2015-0453 28 Oct 2015 County Durham and Darlington

G4S National Offender Management Service

Concerns summary HMP Durham had a serious drug problem, but staff lacked awareness and training on overdose policies, leading to complacent responses, inadequate treatment plans, and delayed emergency calls for prisoners under the influence.

Jacques Lakeman and Torin Lakeman

2015-0191 15 May 2015 Manchester (West)

Concerns 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.

Hana Elhamid

2015-0194 13 May 2015 London (North)

Department of Health and Social Care

Concerns summary Lack of routine blood tests for sugar in a patient on Clozapine treatment led to an undiagnosed diabetic coma, with resultant trachea injury, directly causing death.

Polly Carpenter

2014-0469 28 Oct 2014 Exeter & Great Devon

Devon Partnership NHS Trust

Concerns summary The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.

Samuel Duckworth

2014-0456 20 Oct 2014 London (Inner South)

Department of Health and Social Care

Concerns summary The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.

Clare Bain

2014-0359 5 Aug 2014

South West Ambulance Service

Concerns summary Paramedics lacked awareness that Naloxone's antagonism duration might be shorter than Methadone's respiratory depressant effects, risking patient deaths due to inadequate repeat treatment.

Akua Anokye-Boateng

2014-0211 9 May 2014 London (Inner South)

Medicines and Healthcare Products Regul…

Concerns summary There is a lack of clear guidance and awareness among clinicians about the risks of single-dose NSAIDs causing gastro-intestinal damage in children with sickle cell disease, particularly concerning routine GI protection.

Jason Nock

2014-0013 13 Jan 2014 Black Country

Concerns 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 taken summary The Home Office has requested advice from the Advisory Council on the Misuse of Drugs and is actively collecting evidence on AH-7921. They are also leading an expert panel review to enhance the UK's r

Martin McGlasson

2014-0001 6 Jan 2014 Cumbria (North & West)

British Precast Concrete Federation

Concerns summary Widespread use of an unsafe work method, failure to implement inexpensive safety measures despite known risks, and inadequate dissemination of risk assessments to operating staff were key concerns.

Action taken summary Thomas Armstrong Holdings Ltd has implemented a new system of work and adopted a new Risk Assessment and Method Statement for moving staircases. They have also provided health and safety training for

Joseph Drew Whiteside

2013-0377 16 Dec 2013 Staffordshire (South)

East Staffordshire Borough Council

Concerns summary Numerous drownings of intoxicated individuals in the River Trent highlight the need for improved safety measures, such as fencing and warning signs, at main access points.

Action taken summary The Council appointed the Royal Society for the Prevention of Accidents (RoSPA) to conduct inland water safety reviews across Burton-upon-Trent and Uttoxeter, which was completed in late 2013. The Cou

Keith Nottle

2022-0189 Nottingham City and Nottinghamshire

Nottinghamshire Healthcare Trust and Tu…

Concerns summary Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of care coordination for complex patients and unclear multi-disciplinary team decision-making.

Action taken summary Turning Point has reviewed and refreshed the role of helpline workers, agreed a new Standard Operating Procedure for referrals to the Crisis Team, introduced additional monitoring and audits, and deve

Luke Flynn

2022-0191 Inner North London

Metropolitan Police

Concerns summary The Metropolitan Police lack a policy on handcuff use when requested by medical staff for hospital patients with medical conditions, not mental health issues.

Action taken summary The Metropolitan Police reviewed the concern and stated their existing Handcuff Policy (published Nov 2021) is sufficiently robust for officers to make informed decisions in any setting, including hea

Peter Moorby

2022-0194 Cumbria

Cumbria County Council

Concerns summary A low, unlit wall provides inadequate protection from an 8-10 foot drop into a dangerous river, creating a significant risk of future accidental deaths.

Action taken summary This resident strongly disputes the need for further action regarding the low wall, stating the death was a single unfortunate accident by an intoxicated individual. They argue that raising the wall w

Michael Vince

2022-0198 East London

North East London Foundation Trust and …

Concerns summary A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of PRN use, and dependence evidence was not shared between health trusts.

Action taken summary North East London Foundation Trust (NELFT) arranged a wider learning review led by its pharmacy department and developed an action plan in response to the inquest findings. NELFT has updated its pract

Paul Meadows

2022-0201 Suffolk

Department of Health and Social Care Ipswich and East Suffolk Clinical Commi…

Concerns summary Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning failures within the First Response Service nationally.

Action taken summary The Department of Health and Social Care is overseeing specific actions at the Norfolk & Suffolk NHS Foundation Trust, including a CQC warning notice, an NHS England Recovery Support Programme, and a