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 6 Historic 75 Pending 14
AI Classification
Action Taken 55%
Action Planned 25%
Noted 12%
Disputed 7%
Based on 354 classified responses
Reports by Quarter
Clear
PFD Reports
371 results
Kane Boyce
All Responded
2024-0034 17 Jan 2024 Nottingham and Nottinghamshire
HM Prison and Probation Service Sodexo
Concerns summary Prison staff deliberately ignored cell bells, lacked policy for isolating cell power, failed to follow "under the influence" protocols, and misunderstood key date suicide risk, highlighting systemic safety failures.
Action taken summary Sodexo outlines its currently implemented comprehensive training for staff on ACCT, ACCT Assessor, and Case Coordinators, using HMPPS national packages. They also describe existing processes for Early
Sarah Mitchell
All Responded
2024-0012 8 Jan 2024 Suffolk
Department of Health and Social Care Rosedale Surgery Lowestoft James Paget University Hospitals NHS Tr… +1 more
Concerns summary Hospital staff dangerously dispensed excessive medication to a patient at high risk of overdose because they lacked access to her medical records detailing a controlled dispensing regime.
Action taken summary NHS England refers the coroner to the Norfolk and Waveney ICB for Shared Care Records and James Paget University Hospitals NHS Trust for specific care and prescribing policies. It notes that all PFD r
Joy Ebanks
All Responded
2024-0002 2 Jan 2024 Bedfordshire and Luton
Kirby Road Surgery
Concerns summary Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Action taken summary Kirby Road Surgery has ensured all clinical staff completed training on reducing opioid prescribing and CBT for chronic pain. They have updated and ratified their Opioid and Gabapentinoid Prescribing
Barbara Woodman
All Responded
2024-0100 22 Dec 2023 Surrey
Surrey and Borders Partnership NHS Foun… Surrey County Council NHS England +1 more
Concerns summary Missed opportunities for collateral history gathering, inaccessible information systems, inadequate risk assessment handling, and poorly recorded care plans collectively hindered effective mental health support.
Action taken summary NHS England detailed existing national solutions for patient information sharing, including the National Care Records Service (NCRS) and Summary Care Record (SCR), accessible by authorized mental heal
Kimberley Liu
All Responded
2023-0544 21 Dec 2023 Inner North London
Department for Culture Department for Culture, Media and Sport
Concerns summary Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.
Action taken summary The Department of Health and Social Care notes existing efforts by the MHRA to combat illegal online drug sales. In response to concerns, they launched a national near real-time suspected suicide surv
Linda Banks
All Responded
2023-0533 19 Dec 2023 County Durham and Darlington
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary Identified systemic failures in mental health services were not effectively addressed. Significant delays in Serious Incident Investigations (9 months) compromise evidence quality, hindering prompt learning and improvement in patient safety.
Action taken summary The Trust states that all actions from the thematic review have been addressed, with remaining training to be completed. They have also fully implemented the Patient Safety Incident Response Framework
Claire Briggs
All Responded
2023-0513 8 Dec 2023 Manchester South
Lancashire and South Cumbria Integrated… Greater Manchester Police Cheshire Constabulary +10 more
Concerns summary A stalled Joint Operating Protocol between emergency services leaves a critical lack of clarity on roles and escalation procedures for drug overdose incidents, risking patient safety.
Action taken summary NHS England mandated robust clinical oversight for overdose calls in 2019 and issued national guidance for Ambulance Services relating to overdoses and suicidal intent in April 2021. It also outlined
Charlene Roberts
All Responded
2023-0516 8 Dec 2023 Manchester North
Royal College of Psychiatrists NHS England Greater Manchester Health and Social Ca… +1 more
Concerns summary Systemic failures in managing a complex patient included unquestioned long-term cyclizine prescribing, inadequate supervision, and a lack of specialist dual-diagnosis treatment options, allowing the patient to self-harm.
Action taken summary NHS England clarified that the Controlled Drugs Local Intelligence Network is not for patient information sharing on non-controlled drugs. They have established an all-age eating disorder Clinical Ref
Angela Collins
All Responded
2023-0496 4 Dec 2023 Bedfordshire and Luton
East London NHS Foundation Trust
Concerns summary Vulnerable adults under secondary mental health services who are at risk of prescription drug overdose and mental health crisis receive insufficient or no support.
Action taken summary East London NHS Foundation Trust plans to implement mandatory case reviews for service users who do not engage after a significant event, ensure discussion of escalation pathways, and work with partne
Glyn Ackerley
All Responded
2023-0478 27 Nov 2023 Cheshire
Department of Health and Social Care
Concerns summary The NHS Pathways system fails to differentiate between high and low-risk overdoses, potentially delaying urgent treatment for fatal opiate overdoses, and the implementation of proposed changes is unclear.
Action taken summary NHS England completed a formal review of the opiate overdose clinical pathway in October 2023 and introduced new questions into NHS Pathways in November 2023 to help differentiate higher-risk patients
Zulfiqar Hussain
All Responded
2023-0476 24 Nov 2023 Manchester North
Croft Shifa Health Centre
Concerns summary Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.
Action taken summary The practice updated its document management policy to ensure high-risk patient correspondence is sent to GPs, with two designated staff members managing this process. They clarified that an alert for
Katie Williams
All Responded
2023-0512 24 Nov 2023 Plymouth, Torbay and South Devon
Intensive Care Medicine
Concerns summary The unexpected interaction of a specific medication with common overdose complications re-precipitated serotonin syndrome, highlighting a risk that other NHS organisations may not fully appreciate these medication interaction risks.
Action taken summary The Trust has contacted The Faculty of Intensive Care Medicine to assist with sharing national information about fentanyl risks. They have also decided to communicate the issue with the SW Critical Ca
Glenn Lockwood
All Responded
2023-0487 17 Nov 2023 Inner North London
Limehouse Practice
Concerns summary Insufficient monitoring for Pregabalin abuse in a patient with a known drug abuse history was identified, and the review of record-keeping and prescribing issues for the drug was found to be inadequate.
Action taken summary This document is the Coroner's summing up, outlining their findings regarding Mr Lockwood's death and stating the decision to issue a Prevention of Future Deaths report to The Limehouse Practice due t
Frances Newbury
All Responded
2023-0443 10 Nov 2023 Inner North London
London Ambulance Service NHS Trust
Concerns summary Paramedics failed to administer Naloxone despite a patient's reported illicit drug use and clear physical signs. This highlights a missed opportunity for potentially life-saving intervention in opiate overdose cases.
Action taken summary The London Ambulance Service explains that naloxone was not administered as there was no immediate indication of opioid use, a feasible cause for cardiac arrest was identified, and an expert witness d
Leya Adris
All Responded
2023-0433 8 Nov 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health N… Birmingham and Solihull Integrated Care…
Concerns summary A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by the single point of access system.
Action taken summary Birmingham and Solihull Mental Health NHS Foundation Trust has altered its referral form to clarify that the Community Mental Health and Wellbeing Service will review and determine patient needs, remo
Jacqueline Carrey
All Responded
2023-0411 26 Oct 2023 Milton Keynes
Milton Keynes University Hospital
Concerns summary The patient's medical record lacked clear indication of potential abuse risk, and this crucial information was not flagged to staff before discharge, highlighting failures in record-keeping and communication.
Action taken summary The hospital has incorporated new measures into its Electronic Health Record, including a question on the Pharmacy Medication History Form about limited community supply and prominent 'limited supply'
Mark McKessy
All Responded
2023-0377 9 Oct 2023 Manchester South
One Stockport Health and Care Board
Concerns summary Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.
Action taken summary Stockport Integrated Care Partnership plans a joint learning event in January 2024 with all involved agencies to agree a joint action plan for strengthening information sharing and improving practice
Lilian Board
All Responded
2023-0368 5 Oct 2023 Lincolnshire
United Lincolnshire Hospitals NHS Trust
Concerns summary A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.
Action taken summary The Trust states its policy of providing a 14-day supply of medication upon discharge is standard practice, agreed with primary care partners, and considered appropriate to prevent harm from medicatio
Paula Lenihan
All Responded
2023-0360 2 Oct 2023 Birmingham and Solihull
Birmingham and Solihull Mental Health F…
Concerns summary The Trust has a systemic failure in completing and updating patient risk assessments, risking future deaths. A task group addressing this issue is in its early stages, providing no immediate resolution.
Action taken summary The Trust disputes that the failure to update the risk assessment contributed to the death but has provided dedicated staff time for risk documentation, established a project group to review the risk
Sebastian Daniels
All Responded
2023-0346 22 Sep 2023 Hampshire, Portsmouth and Southampton
Southern Health NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust
Concerns summary Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital annual blood tests due to inconvenient separate phlebotomy appointments.
Action taken summary The Trust has updated procedures for telephone escalation of abnormal triglyceride levels and shared a case study with the Royal College of Pathologists. They are also updating junior doctor induction
Melvyn Blount
All Responded
2023-0345 21 Sep 2023 Derby and Derbyshire
Lister House Oakwood
Concerns summary A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, risks patients missing crucial medication information.
Action taken summary The practice has implemented new policies requiring direct GP-patient communication or documented non-prescriber communication for drug alerts when a GP prescribes at a non-prescriber's behest. They a
Stephen Cassidy
All Responded
2023-0337 19 Sep 2023 Avon
North Bristol NHS Trust
Concerns summary Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Action taken summary NHS England explains national access prerequisites for the Summary Care Record (SCR) and highlights the National Care Records Service (NCRS) as an improved successor. They are delivering the Federated
Talia Phillips
All Responded
2023-0318 4 Sep 2023 Cornwall and the Isles of Scilly
National Institute for Health and Care … British National Formulary
Concerns summary Fluoxetine prescribing guidance lacks recommendations for routine blood level testing, even with symptoms like palpitations, potentially missing chronically high levels and warranting review.
Action taken summary NICE acknowledged the concern but stated that the Medicines and Healthcare products Regulatory Agency (MHRA) is best placed to address monitoring requirements for fluoxetine, as these are covered by t
Stephen Ratclife
All Responded
2023-0492 1 Sep 2023 Manchester North
Greater Manchester Integrated Care Part…
Concerns summary The absence of a specialist service for GPs to refer patients with difficult venous access for blood tests led to a missed diabetes diagnosis.
Action taken summary The organisation has undertaken a review of phlebotomy provision to identify variations and intends to improve consistency. Learning will be shared with various groups and cascaded to professionals, w
Edward Rhodes
All Responded
2023-0280 1 Aug 2023 Dorset
Beaufort Road Surgery
Concerns summary There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely on verbal discussions without an automatic referral system or written confirmation, leading to unmet care.
Action taken summary Following a multi-disciplinary meeting, Beaufort Road Surgery confirmed that a 90-day sobriety period is not a referral criterion for CMHT and that referrals for patients with alcohol addiction would