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
PFD Reports
548 results
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
Susan Gladstone
Historic (No Identified Response)
2023-0485 20 Nov 2023 Hertfordshire
REDACTED
Concerns summary A fatal interaction between tramadol and warfarin occurred due to a lack of warnings for prescribing doctors about this known drug interaction, leading to dangerously high INR levels.
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
Roger Stevenson
Partially Responded
2023-0446 13 Nov 2023 Mid Kent and Medway
Department of Health and Social Care NHS England
Concerns summary A vulnerable adult with chronic mental ill health was "lost in the system" due to inadequate follow-up, delayed access to services, and lack of proactive support. Staffing shortages and poor family engagement further jeopardized care.
Action taken summary The Department of Health and Social Care has significantly invested in transforming community mental health services and has implemented 24/7 urgent mental health helplines in every local area. They a
John Pace
Partially Responded
2023-0447 13 Nov 2023 Essex
Castle Rock Group Forward Trust
Concerns summary A new methadone detoxification discharge pathway for prisoners lacks formal documentation, policies, or written procedures. This absence prevents consistent implementation and monitoring, posing a risk to future prisoners' safety.
Action taken summary The Forward Trust has drafted and implemented a new 'Management of Non-engaging Service Users Protocol,' which has been published on their Intranet. They have also facilitated a dissemination and trai
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 Integrated Care… Birmingham and Solihull Mental Health N…
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
Steven Sanders
Partially Responded
2023-0356 29 Sep 2023 Birmingham and Solihull
Care Quality Commission West Midlands Police St Andrew’s Healthcare
Concerns summary An endemic problem of illicit drug use and supply within the secure mental health hospital, inadequately mitigated, poses significant risk to vulnerable patients with mental illness and compromised judgment.
Action taken summary The CQC requested that the Chief Coroner’s Office issue guidance to all coroners, ensuring timely notification of inquests and prompt submission of Regulation 28 reports and responses to a dedicated C
Sebastian Daniels
All Responded
2023-0346 22 Sep 2023 Hampshire, Portsmouth and Southampton
Hampshire Hospitals NHS Foundation Trust Southern Health 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
Kristopher Tilbury
Historic (No Identified Response)
2023-0331Deceased 8 Sep 2023 Hertfordshire
Ministry of Justice HMP The Mount
Concerns summary HMP The Mount failed to control illicit drug supply, including psychoactive substances, leading to high availability even on a 'Wellbeing Wing' and multiple subsequent drug-related deaths.
Talia Phillips
All Responded
2023-0318 4 Sep 2023 Cornwall and the Isles of Scilly
British National Formulary National Institute for Health and Care …
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
David Celino
Partially Responded
2023-0303 21 Aug 2023 West Yorkshire (Eastern)
West Yorkshire Police Department for Culture Home Office +3 more
Concerns summary Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to preventable deaths.
Action taken summary Festival Republic implemented several improvements for Leeds Festival 2023, including an enhanced safeguarding policy and messaging, increased security with more robust searches and dogs, improved sta
Jacqueline Smith
Partially Responded
2023-0304 21 Aug 2023 West London
Forward Trust Hillingdon Council Central and North West London Mental He…
Concerns summary Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable tenant without effective assistance.
Action taken summary London Borough of Hillingdon has ratified a new Hoarding Policy following Mrs Smith's death, which includes training for frontline housing officers, establishing a new Hoarding Panel for complex cases
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
Stephen Weatherley
All Responded
2023-0269 20 Jul 2023 Inner South London
HM Inspectorate of Prisons Ministry of Justice HM Prison and Probation Service +1 more
Concerns summary Significant issues with data recording and retention in HMP Thameside led to lost critical documents and incomplete records, alongside the absence of a written drug swallow policy.
Action taken summary HM Inspectorate of Prisons clarifies its independent inspection remit, noting that the information from the PFD report regarding HMP Thameside will be used in its ongoing risk assessment for future in
Emily Corfield
All Responded
2023-0247 14 Jul 2023 North Wales East and Central
Betsi Cadwaladr University Health Board Adferiad Recovery
Concerns summary An addiction support service lacked robust communication and record-keeping policies, relying solely on written correspondence, which led to service users being disengaged and facing long waiting times.
Action taken summary Adferiad implemented a new process to scan and save all patient correspondence in individual electronic files. They are also exploring updated automated communication routes, such as a text reminder s
Sean Heeney
All Responded
2023-0250Deceased 14 Jul 2023 Northamptonshire
HM Prison and Probation Service
Concerns summary Bridgewood House lacked a clear plan for safely extricating medically unwell or uncooperative residents from its first floor, compounded by the building's layout, leading to dangerous delays.
Action taken summary HM Prison and Probation Service states that Bridgewood House Approved Premises is consulting with local emergency services to prepare a plan for the extrication of individuals from the first floor dur
[REDACTED]
All Responded
2023-0234 5 Jul 2023 Inner North London
Metropolitan Police Service
Concerns summary Officers struggled to recognise the point for immediate CPR, delaying its commencement, and there was a lack of proactive, focused support from secondary safety officers during a critical incident.