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). 54% 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 54%

Action Planned 26%

Noted 13%

Disputed 8%

Based on 463 classified responses

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PFD Reports

548 results

Jennifer Lacey

Partially Responded

2018-0315 24 Oct 2018 London Inner (West)

GPC NHS England

Concerns summary Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled by UK pharmacies without adequate checks.

Joshua Edwards

2018-0335 2 Oct 2018 West Yorkshire (East)

Leeds City Council

Concerns summary Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event organizers need to brief staff and public on emergency vehicle priority.

Paul Ryley

2018-0284 14 Sep 2018 Birmingham and Solihull

Concerns summary Unclear Toxbase guidelines for paracetamol overdose re-presentations lead clinicians to misunderstand their applicability, risking patients not receiving crucial treatment for liver toxicity.

Scott Carton

Historic (No Identified Response)

2018-0287 7 Sep 2018 West Yorkshire (East)

MOJ National Probation Service

Concerns summary Inadequate psychological support for prisoners with mental health and drug issues upon release, including unsuitable hostel placements without specialist input, compromises rehabilitation and increases re-offending risk.

Colin Griffiths

2018-0295 4 Sep 2018 London Inner (North)

Concerns summary Medical history recording relies solely on verbal communication, leading to inaccuracies, and there is no audit system to verify the accuracy of patient records made by nurses.

Ian Wolstenholme

Partially Responded

2018-0272 8 Aug 2018 Manchester (North)

Medicines and Healthcare products Regul… Department of Health and Social Care

Concerns summary A lack of national guidance for clinicians on co-prescribing multiple highly addictive and potentially harmful drugs creates a risk of serious harm or death from combined drug toxicity.

Ellie Knowles

Historic (No Identified Response)

2018-0202 18 Jul 2018 Newcastle Upon Tyne

Hoults Limited Shindig Events Limited

Concerns summary A venue maintains a license for high-risk events but lacks a robust internal protocol requiring consultation with police and council licensing officers before planning similar future events.

Eugeniusz Niedziolko

10 Jul 2018 Wiltshire and Swindon

Concerns summary Police lacked appropriate options for managing a heavily intoxicated individual, leading to them being left alone in a public lavatory on a cold night, resulting in death.

David Travers

2018-0188 22 Jun 2018 Plymouth Torbay and South Devon

Devon Local Medical Committee NHS Northern Eastern and Western Devon …

Concerns summary It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.

Darren Carrington

2018-0181 15 Jun 2018 Brighton and Hove

North Laine Medical Centre Brighton and Hove Clinical Commissionin…

Concerns summary The provided concerns text was insufficient to identify specific safety issues or systemic failures.

Neil Jones

Historic (No Identified Response)

2018-0163 25 May 2018 Warwickshire

Warwickshire County Council

Concerns summary Repeated fatal road traffic collisions at a specific site, despite speed limit reduction, highlight the urgent need for a determined casualty reduction scheme.

Sara Moran

2018-0133 28 Apr 2018 Blackpool & Fylde

Department of Health and Social Care

Concerns summary Excessive caseloads for mental health professionals risk individuals not receiving adequate attention, potentially leading to fatal outcomes for vulnerable service users.

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.

Matthew Gayle

Historic (No Identified Response)

2018-0092 27 Mar 2018 Staffordshire (South)

Department of Health and Social Care

Concerns summary Insufficient numbers of consultant histopathologists and a lack of compulsory training in coroner's autopsies risk incomplete death investigations, as exemplified by a missed histology opportunity.

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.

Angela Byrne

Historic (No Identified Response)

2018-0042 13 Feb 2018 London Inner (West)

Wandsworth Consortium Drug and Alcohol …

Concerns summary W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with inconsistent records.

Michael Spencer

Historic (No Identified Response)

2018-0032 5 Feb 2018 South Yorkshire (West)

Medicines and Healthcare products Regul…

Concerns summary A specific drug (Andexanet alfa) to reverse potentially fatal bleeding caused by Factor Xa inhibitor anticoagulants is not available in the UK, even for compassionate use.

Naomi Sourbut

19 Dec 2017 Exeter and Greater Devon

Concerns summary Recommendations from a 2017 root cause analysis report regarding suicidal ideation and protective factors for individuals expressing intent to self-harm were not clearly implemented.

Steven Fone

Historic (No Identified Response)

2017-0101 27 Mar 2017 Manchester (South)

Concerns summary The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.

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.

Shane Hardy

16 Jan 2017 Gloucestershire

Concerns summary Individuals with co-occurring addictions and mental health issues fell through service gaps, receiving no assistance. Additionally, there was a lack of inter-agency information sharing and no identified lead agency for communication.

Mark Lilliott

Historic (No Identified Response)

2016-0453 16 Dec 2016 Liverpool and Wirral

Concerns summary Delays in accessing a radio-equipped senior officer for emergency assistance within the prison, exacerbated by noise on the wing, could critically impede swift responses in future emergencies.

Robert Lloyd

Partially Responded

2016-0425 29 Nov 2016 Cornwall and Isles of Scilly

St Mary’s Health Centre Cornwall Council Addaction

Concerns summary Geographical isolation and reduced transport options severely limited face-to-face alcohol support services, leading to reliance on less effective video links and decreased engagement for island residents.

Mark Yafai

Historic (No Identified Response)

2016-0403 9 Nov 2016 Coventry

West Midlands Police

Concerns summary Custody policies use unclear terminology for drug influence, granting officers excessive discretion in risk assessments and leading to inadequate Health Care Professional involvement.