Mental Health related deaths
PFD Category
Reports: 636
Areas: 69
Earliest: Aug 2013
Latest: 14 Apr 2026
77% response rate (above 63% average). 45% of classified responses show concrete action taken. Reports rose 94% from 33 (2023) to 64 (2024).
PFD Reports
636 resultsMelanie Elms
Historic (No Identified Response)
2022-0079
7 Mar 2022
County of Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary)
The patient's care package was not adequately followed, critical risk assessments prior to leave were insufficient or unrecorded, and there was no proper missing person plan in place.
Sarah-Louise Doyle
Partially Responded
2022-0070
4 Mar 2022
Liverpool and Wirral
Mersey Care NHS Foundation Trust
Merseyside Police
Concerns summary (AI summary)
Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.
Action Taken
(AI summary)
The Trust has already taken actions, including issuing urgent instructions on recording intermittent observations, discussing the report at safety huddles, ensuring competency updates for staff, conducting spot checks on observation forms, and reviewing the Ward Assurance Audit to reflect the need for unpredictable observation intervals.
Stephanie Moyce
Historic (No Identified Response)
2022-0059
25 Feb 2022
Essex
Essex Partnership University NHS Founda…
Concerns summary (AI summary)
Conspicuous lack of clarity regarding responsibility for discharge planning, post-discharge oversight, and safety-netting for psychotherapy patients without a Care Coordinator was identified.
Amanda Gibbens
Historic (No Identified Response)
2022-0061
23 Feb 2022
Buckinghamshire
Oxford Health NHS Foundation Trust
Concerns summary (AI summary)
Ineffective "within eyesight" observations due to continued reliance on monitor screens and inadequate bedroom search processes failed to remove self-harm items, despite prior warnings.
Jane Shilton
All Responded
2022-0053
22 Feb 2022
Leicester City and South Leicestershire
Hamilton Community Homes Ltd
Concerns summary (AI summary)
The quality of online first aid training and the minimum 3-year training interval are insufficient for staff caring for vulnerable residents with complex mental health and substance misuse needs.
Action Taken
(AI summary)
Hamilton Community Homes has implemented several measures, including having one awake staff member on night shifts, updating alcohol and room search policies, implementing signature sheets for care plan and medication understanding, updating training policy for mental health, mandating annual first aid training, and issuing two-way radios to staff.
Daniel France
Historic (No Identified Response)
2022-0047
16 Feb 2022
Cambridgeshire and Peterborough
Cambridgeshire and Peterborough NHS Fou…
Concerns summary (AI summary)
A vulnerable young person known to the County Council and Mental Health Trust did not receive timely support, facing a long wait for psychological therapy, potentially dangerous given the risk of impulsive acts; there were also considerable delays in obtaining appointments for the Gender Identity Clinic and a shortage of psychological therapies.
Theo Brennan-Hulme
All Responded
2022-0049
15 Feb 2022
Norfolk
Hellesdon Hospital
Concerns summary (AI summary)
A persistent culture of bullying and lack of compassion within the Crisis Resolution Home Treatment Team led to a dangerous belief that some suicides are "inevitable," compounded by unchecked patient discharge decisions.
Action Taken
(AI summary)
Hellesdon Hospital has updated its discharge policy to include a documented discussion and MDT review prior to discharge, particularly for young people. They are also working with service users to improve communication and engaging in suicide prevention initiatives.
Jason Lennon
Historic (No Identified Response)
2022-0048
15 Feb 2022
East London
Department of Health and Social Care, E…
The National Quality Board
Concerns summary (AI summary)
Failures in mental health care involved not using an appropriate care pathway, a flawed clinical review with poor record-keeping and communication, an incomplete incident action plan, and no regulatory referral for staff failings.
Matthew McManus
All Responded
2022-0044
11 Feb 2022
Greater Manchester South
Department of Health and Social Care
Greater Manchester Health and Social Ca…
Concerns summary (AI summary)
An adult with complex mental health and social care needs lacked coordinated care and a single point of contact, resulting in inadequate assessment, information sharing, and risk management.
Action Planned
(AI summary)
Greater Manchester Health & Social Care Partnership acknowledges the potential gap in support for patients with complex needs and describes initiatives to improve data sharing, training, and oversight. They plan to present learning to the Greater Manchester Quality Board and cascade learning through governance and learning forums. The Department of Health and Social Care is implementing the Community Mental Health Framework (CMHF) to improve joined-up support across health and social care, aiming for all areas to have these models in place by the end of 2023/24. It also highlights increased collaboration through the Health and Care Act 2022 and the government's integration white paper.
Sheila Steggles
All Responded
2022-0042
10 Feb 2022
Norfolk
Hellesdon Hospital
Concerns summary (AI summary)
Patient care failures included neglected VTE risk assessments for reduced mobility, poor clinical documentation, inadequate care planning, and junior staff failing to consult on critical medication interactions.
Action Taken
(AI summary)
Hellesdon Hospital is updating the Trust induction for junior doctors to include physical health training, supported by senior consultants and underpinned by the SBAR framework. They will offer "3 Ps" training to all staff, rolling out "bite-size" training on VTE, and set up a working group for flexible working colleagues to support an education passport for health workers.
Benjamin Stroud
Historic (No Identified Response)
2022-0039
8 Feb 2022
Essex
Essex Partnership University Trust and …
Concerns summary (AI summary)
A patient's case was not referred to the Multi-Disciplinary Team, denying essential psychiatric input, as the Care Coordinator made un-documented clinical decisions regarding referrals, posing a significant risk.
Joy Burgess
All Responded
2022-0038
4 Feb 2022
Greater Manchester South
Department of Health and Social Care
Concerns summary (AI summary)
Mental health patients face 'chaotic' ward environments unsuitable for recovery due to resource limitations, alongside lengthy waiting times (around one year) for psychological therapies.
Action Planned
(AI summary)
The Department of Health and Social Care references NHS England's consultation on new waiting time standards for mental health services and states they are working on the next steps following the consultation.
Sarah Gilbert-Jones
All Responded
2022-0037
4 Feb 2022
South Wales Central
Welsh Ambulance NHS Trust
Concerns summary (AI summary)
Emergency call handling failed to appropriately categorise a time-critical overdose due to protocol shortcomings and clinical misjudgment, leading to significant delays and inconsistent response vehicle deployment.
Action Planned
(AI summary)
The Welsh Ambulance Services NHS Trust is considering a specific question set within the Medical Priority Dispatch System (MPDS) to identify propranolol overdoses, and has an existing Standard Operating Procedure for flagging overdose cases to dispatchers. The trust is also proposing further actions outlined in an attached plan.
Carol Cole
All Responded
2022-0033
2 Feb 2022
Dorset
Dorset Council
Dorset Police
Concerns summary (AI summary)
A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.
Action Planned
(AI summary)
Dorset Council will fund a co-located member of staff in the MASH to share PPNs with GPs. A further review with Health partners commenced on 12 April 2022 to review the current process. Dorset Council amended its internal process on 25/02/22 so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. Dorset Council will provide additional staffing resources to MASH to assist with the sharing of PPNs to GPs pending a wider system review.
Oskar Nash
All Responded
2022-0031
31 Jan 2022
Surrey
Department for Education
Department of Health and Social Care
National Child Safeguarding Review Panel
+3 more
Concerns summary (AI summary)
Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.
Action Planned
(AI summary)
The council made Autism awareness training mandatory for all staff working directly with children and young people, to be completed by 31 March 2022. It noted the Coroner's concern regarding post-death reviews, stating that SCC follows national guidance and took appropriate steps by way of a Thematic Review which was accepted by the National Panel. The CCG details actions taken including a Surrey CDR team meeting, incorporating thematic review learning into Surrey Children Services academy training, establishing a multi-agency task and finish group and a children and young person subgroup of the Surrey Suicide Prevention Partnership. Oskar's death will be presented at the next suicide themed CDOP meeting and learning shared nationally via NCMD. The Department for Education is conducting reviews of special educational needs and disability and of the children’s social care system, which will lead to significant reform of the support available for the most vulnerable of children and young people. The Child Safeguarding Practice Review Panel are developing a framework for undertaking rapid reviews, developing a quality assurance framework and publishing anonymised examples of good quality rapid reviews as exemplars of good practice.
Jack Taylor
All Responded
2022-0029
28 Jan 2022
West Sussex
Sussex Partnership NHS Foundation Trust
Sussex Police
Concerns summary (AI summary)
Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Action Planned
(AI summary)
Sussex Partnership NHS Foundation Trust, working with Sussex Police, established a working group to improve the joint response to patients absent without leave, proposing solutions including a Missing Persons Template and updated risk assessment processes. An improved escalation process has been implemented and added to the AWOL Policy and the AWOL reduction project is being rolled out across the Trust. Sussex Police is co-developing a Missing Persons Template with SPFT to improve information sharing and is reviewing existing training for Sergeants on missing person investigations, with potential enhancements. The force also plans to review the structure of the Missing Persons Team to enhance support to colleagues.
Adam Stone
All Responded
2022-0026
27 Jan 2022
Birmingham and Solihull
College of Paramedics, The Association …
Concerns summary (AI summary)
Acute Behavioural Disturbance, a medical emergency with high mortality risk, is inappropriately categorized as a Category 2 ambulance response, potentially causing dangerous delays in urgent medical care.
Noted
(AI summary)
NHS England and NHS Improvement are writing to ambulance services regarding clinical oversight, including a reminder that Acute Behavioural Disturbance (ABD) calls should have oversight of a senior clinician in the control room and calls should be upgraded to Category 1 if the patient’s condition deteriorates or if the patient is being restrained. The Association of Ambulance Chief Executives (AACE) explains its role and states that it cannot mandate response categories. AACE developed and issued national clinical guidance in 2019, updated in 2020, to UK ambulance clinicians, supported education and presented at conferences and webinars for police and ambulance staff, and continues to develop further guidance around managing patients with extreme agitation. The College of Paramedics clarifies it is not responsible for setting standards for paramedic education, training, or practice, but will ensure its pre-registration curricula review includes the latest evidence on Acute Behavioural Disturbance. The College endorses AACE's response and will share the correspondence with NHS England’s Emergency Call Prioritisation Advisory Group and AACE to propose a review of the current response categorisation of Acute Behavioural Disturbance. NHS Digital provides background information on NHS Pathways, a clinical decision support system used by NHS 111 and some ambulance services, and its governance structure. It states that NHS Pathways is concordant with NICE, the UK Resuscitation Council, and the UK Sepsis Trust guidelines.
Finnian Kitson
All Responded
2022-0023
27 Jan 2022
Manchester City
Universities and Colleges Admissions Se…
Concerns summary (AI summary)
Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.
Noted
(AI summary)
UCAS provides context on how students can share information about support needs within their application and how universities then arrange support. They highlight that the information is optional and handled confidentially, and doesn't impact academic judgement.
Manon Jones
Historic (No Identified Response)
2022-0174
26 Jan 2022
South Wales Central
Cwm Taf Morgannwg University Health Boa…
Concerns summary (AI summary)
Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.
Ketheeswaren Kunarathnam
All Responded
2022-0030
26 Jan 2022
West London
Home Office
Concerns summary (AI summary)
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Action Taken
(AI summary)
The Home Office outlines actions taken to address concerns, including mandatory training for officials engaged in detention, focusing on best practice and vulnerability, and Self Harm Awareness Sessions run by HMPPS for front-line immigration officers in prisons. They also highlight improvements to the Adults at Risk in Immigration Detention policy and the introduction of Detention Case Progress Panels.
Idris Habib
All Responded
2022-0020
24 Jan 2022
Mid Kent and Medway
HMP Swaleside
Concerns summary (AI summary)
Medication from a previous occupant was found in the deceased's cell, indicating poor cell management. A significant disconnect also existed between prison policy and officers' actions.
Action Taken
(AI summary)
HMP Swaleside issued a notice in November 2021 reminding staff of cell clearance procedures and reinforced the process during staff briefings. Since the inquest, the prison has introduced a welfare check at approximately 8am requiring staff to gain a verbal response from the occupant, with completion of the check recorded in the wing assurance book, with staff re-issued a notice to remind them to satisfy themselves of the prisoner's wellbeing.
Michelle Whitehead
All Responded
2022-0016
19 Jan 2022
Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary (AI summary)
The report identifies concerns relating to sedation medication (unclear dose/type, possible excess, poor documentation), delayed recognition of patient's declining condition, lack of medical clerking and consultant involvement, delays in contacting the duty doctor and paramedics, and delays in paramedics accessing the ward; the coroner notes these issues have been raised in previous inquests.
Action Planned
(AI summary)
Following a medication error, staff received supervision and completed self-reflection. The Trust is conducting an audit, creating a Quality Improvement Plan, and plans to share learnings with the family and the coroner by the end of May 2022.
Luke Wilden
All Responded
2022-0015
16 Jan 2022
Bedfordshire and Luton
East London NHS Foundation Trust
NHS England
Concerns summary (AI summary)
Inadequate transition arrangements within mental health services for young adults with high-functioning autism resulted in a lack of continued treatment and appropriate social care. This service gap may exist nationally.
Action Planned
(AI summary)
NHS England is working with ELFT to strengthen knowledge and understanding of transitions issues in each other’s areas and a shared transition protocol or protocols that link together. They are committed to improving the availability of inpatient mental health support and alternatives to admission for Children and Young People. The Trust has reinforced transition protocols, reviewed the serious incident report into Mr Wilden’s death and the Trust’s transition policy and protocols with relevant staff members. An administrator pulls a list of all existing service users on a monthly basis to address the transitions policy.
Jan Goodliffe
Historic (No Identified Response)
2022-0009
14 Jan 2022
Essex
NHS England and Essex Partnership Unive…
Concerns summary (AI summary)
Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
James Emmerson
Historic (No Identified Response)
2022-0002
5 Jan 2022
Bedfordshire and Luton
Association of Directors of Adult Socia…
Department of Health and Social Care
East London NHS Foundation Trust
+2 more
Concerns summary (AI summary)
Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health Professional, increasing risk of self-harm or suicide.