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).

Response Status
Responded 444 No Response 7 Historic 75 Pending 13
AI Classification
Action Taken 55%
Action Planned 27%
Noted 9%
Disputed 9%
Based on 222 classified responses
Reports by Quarter
PFD Reports
548 results
Joshua Leatham-Prosser
All Responded
2025-0110 27 Feb 2025 Dorset
Home Office
Concerns summary Ketamine is easily accessible, perceived as less harmful by teenagers, and its highly addictive nature causes severe, irreversible bladder damage (ketamine cystitis), trapping users in a cycle of dependence.
Action taken summary The Home Office has formally commissioned an updated harms assessment of ketamine from the Advisory Council on the Misuse of Drugs (ACMD) to address concerns about its classification, addictiveness, a
Kim Robinson
All Responded
2025-0055 31 Jan 2025 Suffolk
Department of Health and Social Care
Concerns summary The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Action taken summary The DHSC acknowledged concerns regarding the online prescribing system, referencing existing General Pharmaceutical Council guidance and broader government commitments to suicide prevention and mental
Aeran Taylor
All Responded
2025-0057 31 Jan 2025 West Sussex, Brighton and Hove
Ministry of Defence
Concerns summary Deficient mental health assessments at military discharge, lack of inquiry into drug use linked to potential PTSD, and insufficient long-term rehabilitation options for veterans with substance abuse were identified.
Action taken summary The Ministry of Defence disputed that inquiries into drug use correlation with PTSD and formal mental health assessments at discharge were lacking, stating such checks and Structured Mental Health Ass
William Northcott
All Responded
2025-0069 27 Jan 2025 Devon, Plymouth and Torbay
Devon Partnership NHS Trust Medicines and Healthcare Projects Devon ICB +1 more
Concerns summary Disparities in Clozapine monitoring between specialist clinics and GP practices lead to inadequate patient education on side effects, while guidance also underemphasizes cardiomyopathy risks for this cardiotoxic drug.
Action taken summary NHS Devon will provide additional funding to Devon Partnership NHS Trust in the 2025/26 financial year to implement more Clozapine clinics. They will also ensure that any changes to national policy re
Charlie Marriage
All Responded
2025-0048 24 Jan 2025 Inner South London
NHS England
Concerns summary Patients with "cliff-edge conditions" are not identified within the health system, leading to inadequate patient awareness of risks, poor urgent care recognition, and unreliable emergency medication access.
Action taken summary NHS England has instigated a Medicines Safety Improvement Programme and reviewed/updated the 111 algorithm for medication requests to improve access to "Time Critical Medicines." A new clinical guidel
Tammy Milward
All Responded
2025-0027 15 Jan 2025 Surrey
Surrey and Borders Partnership NHS Foun… Esher Green Surgery
Concerns summary Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.
Action taken summary Esher Green Surgery held a Significant Event Meeting, contacted the ICB, and raised staff awareness regarding fragmented medical records. They will implement any temporary IT integration measures reco
Joshua Forsdyke
All Responded
2025-0014 10 Jan 2025 Inner North London
Fresh Student Living University of Arts London
Concerns summary Ketamine was easily and openly available to students, with drug dealing occurring freely within and between university student halls of residence.
Action taken summary Fresh Student Living plans to improve data sharing with UAL on drug concerns, collaborate on an awareness campaign for students on reporting drug misuse, and add a question to their annual survey abou
Ava Hodgkinson
All Responded
2025-0016 10 Jan 2025 Lancashire and Blackburn with Darwen
Department of Health and Social Care
Concerns summary Current pharmacy restrictions prevent pharmacists from issuing medication in a different strength, even if the correct dosage could be administered, causing dangerous delays in treatment.
Action taken summary The DHSC is exploring new flexibilities for pharmacists to dispense alternative medication strengths without an amended prescription in cases of immediate clinical need. They plan to launch a formal p
Joseph Forbes Black
All Responded
2025-0005 2 Jan 2025 Inner North London
NHS England Department of Health and Social Care
Concerns summary Naloxone kits are not widely available to drug users, especially those not engaged with substance misuse services, despite the increased risk from potent synthetic opioids.
Action taken summary NHS England reports that community pharmacies can now supply naloxone following recent legislative changes. They are also working to disseminate good practice from Islington’s Better Lives service, wh
Alexandra Roberts
All Responded
2025-0006 2 Jan 2025 Cheshire
NHS England
Concerns summary The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
Action taken summary NHS England plans to recommend that annual medication reviews consider patients' mental health and wellbeing when prescribing high-risk medicines like insulin. They will also review prescription quant
James Keen
All Responded
2025-0140 2 Jan 2025 West London
Revon Healthcare
Concerns summary Untrained support workers at supported accommodation conducted physical health checks without understanding results or their implications, leading to unreliable information and a lack of proper training oversight.
Action taken summary Revon Healthcare states that all support workers have completed mandatory and additional physical health monitoring training, enabling them to identify and document abnormal readings. They confirmed a
David Crompton
All Responded
2024-0713 31 Dec 2024 West Yorkshire (Eastern)
Midway Pharmacy General Pharmaceutical Council
Concerns summary The pharmacy repeatedly failed to promptly supply essential anti-epileptic medication, leaving the patient without treatment and lacking clear systems for managing supply shortages.
Action taken summary Midway Pharmacy has reworded its Standard Operating Procedures to emphasize referral to local hospitals for medication shortages and its Superintendent Pharmacist has written to Community Pharmacy Eng
Oliver Winson
All Responded
2024-0699 20 Dec 2024 Norfolk
NHS England
Concerns summary Patients with undiagnosed or untreated ADHD face excessively long waiting lists, leading to potential deterioration, harmful behaviors, and increased risk of death.
Action taken summary NHS England acknowledges extensive national waiting lists for adult ADHD services and the medication shortages, referring to 2023 national guidance for Integrated Care Boards on improving access. They
Susan Karakoc
Partially Responded
2024-0702-wp94642 20 Dec 2024 Nottingham and Nottinghamshire
Department of Health and Social Care Department for Science Financial Conduct Authority +2 more
Concerns summary Search engines readily return websites selling addictive prescription medications, indicating a failure in monitoring online supply chains and detecting criminal financial enterprises.
Action taken summary The DHSC reports that the MHRA previously investigated the website used by the deceased and issued a domain suspension request, resulting in its takedown. The MHRA also plans various future criminal c
Nonie Atshiki
All Responded
2024-0684 11 Dec 2024 Inner North London
St Mungo’s
Concerns summary Hostel night staff lacked essential first aid, CPR, and naloxone training, and the facility did not have a defibrillator, compromising emergency response capabilities for residents.
Action taken summary St Mungo's is relaunching its Solid Foundations process to track First Aid and Responding to Emergencies e-learning and updating its First Aid Policy. It is installing defibrillators in all residentia
Oliver Billings
All Responded
2024-0656 28 Nov 2024 Devon, Plymouth and Torbay
Royal Pharmaceutical Society Pharmacy2U Limited Clare House Surgery
Concerns summary A pharmacy issued a subsequent prescription without confirming the cancellation of a previous one, and rapid dispatch prevented error detection. The patient was inappropriately burdened with resolving the pharmacy's error.
Action taken summary Amicus Health has communicated the critical importance of careful prescription checking to all prescribers, implemented flagging for high-risk patients to ensure closer monitoring and shorter prescrip
Amy Butcher
All Responded
2024-0651 26 Nov 2024 Suffolk
Department of Health and Social Care Norfolk and Suffolk NHS Foundation Trust
Concerns summary The mental health medication prescribing system is confusing and lacks a single point of contact, requiring patients in crisis to contact multiple services. This is compounded by out-of-hours issues and restrictions on certain medications.
Action taken summary Norfolk and Suffolk NHS Trust has implemented a new Standard Operating Procedure for its mental health liaison teams within acute hospitals to clearly outline aims and expectations. They have also rai
Margaret Feeney
Partially Responded CC
2024-0644 25 Nov 2024 Derby and Derbyshire
Department of Health and Social Care Daynight Pharmacy Macklin Street Surgery +1 more
Concerns summary Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Action taken summary Macklin Street Surgery has drafted a new policy for prescribing to high-risk patients around bank holidays, which will be ratified in February 2025 and included in staff training. They will also consu
Jonathon Lawlor
All Responded
2024-0667 25 Nov 2024 Mid Kent and Medway
HM Prison and Probation Service
Concerns summary Due to severe staff shortages, keywork sessions for prisoners were drastically reduced, potentially increasing risks for those in custody, despite guidance recommending weekly meetings.
Action taken summary HMPPS has introduced a new regime and business planning process to increase key work delivery and set core expectations for prisons. HMP Elmley is compiling a Key Work Delivery Strategy for 2025, aimi
Edward Barnard
Partially Responded
2024-0640 21 Nov 2024 London Inner (South)
Royal College of Veterinary Surgeons Veterinary Medicines Directorate
Concerns summary A vulnerable young adult illicitly obtained an animal-licensed substance for suicide, highlighting an emerging risk. Licensing bodies and veterinary societies must examine preventive measures to curb access and prevent future deaths.
Action taken summary The RCVS plans several actions by Spring 2025, including considering additional requirements for veterinary practices to have individualised suicide prevention plans, reviewing guidance on controlled
Yemisi Cielto-Opaleye
All Responded
2024-0635 18 Nov 2024 Inner North London
North London Mental Health Partnership
Concerns summary Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.
Action taken summary North London NHS accepts several concerns and plans to update the Patient Information Leaflet for Olanzapine depot to clearly state the risk of death, and is reviewing its policy and procedure to mini
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
All Responded
2024-0628 15 Nov 2024 London Inner (South)
Care Quality Commission Department of Health and Social Care NHS England +1 more
Concerns summary A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, or the wider industry.
Action taken summary NHS England has established a cross-organisational working group to enhance oversight and information sharing for Section 10 exempt entities. They plan to publish revised guidance with clearer reporti
Hannah Aitken
All Responded
2024-0622 14 Nov 2024 Surrey
Home Office Department of Health and Social Care
Concerns summary The increasing use of for self-harm is not centrally monitored, and current legislation fails to control the import and availability of substances used for poisoning, despite known risks.
Action taken summary The Department of Health and Social Care (DHSC) has established a "Concerning Methods Working Group" to examine access to the substance and other methods of suicide. DHSC is also exploring better use
Kumaran Chetty
All Responded
2024-0629 14 Nov 2024 Greater Manchester South
Brinnington Surgery
Concerns summary The GP surgery failed to identify excessive fentanyl use reported in hospital correspondence, lacking proper triage procedures and specific policies to flag concerns about controlled drug abuse and initiate medication reviews.
Action taken summary The Brinnington Surgery has amended its incoming correspondence process to identify controlled drug prescriptions and updated its controlled drug policy to include maximum prescribing quantities. GPs
Joel Colk
All Responded
2024-0621 13 Nov 2024 West Sussex, Brighton & Hove
South East Coast Ambulance Service NHS … NHS England & NHS Improvement
Concerns summary NHS Pathways' overdose categorization system fails to differentiate severity, leading to delayed responses. Ambulances also lack the necessary antidote for certain ingestions, causing critical treatment delays.
Action taken summary NHS England has commissioned a review of the NHS Pathways overdose pathways, with recommendations to be considered in February 2025 to address concerns about differentiating overdose severity. They st