Mental Health related deaths

PFD Category
Reports: 626 Areas: 69 Earliest: Aug 2013 Latest: 27 Feb 2026

77% response rate (above 62% average). 64% of classified responses show concrete action taken. Reports rose 94% from 33 (2023) to 64 (2024).

Response Status
Responded 485 No Response 5 Historic 122 Pending 5
AI Classification
Action Taken 64%
Action Planned 19%
Noted 12%
Disputed 5%
Based on 296 classified responses
Reports by Quarter
Clear
PFD Reports
419 results
Sam Pringle
All Responded
2020-0101 22 Apr 2020 Manchester South
Greater Manchester Medicines Management… NHS Stockport Clinical Commission Group
Concerns summary Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.
Karen Bingham
All Responded
2020-0081 30 Mar 2020 Surrey
South East Ambulance Service Surrey Constabulary
Concerns summary Police training on mental health conditions is insufficient, and emergency service dispatchers lack understanding of each other's triaging and response systems, leading to coordination failures.
Lewis Francis
All Responded
2020-0074 23 Mar 2020 Exeter and Greater Devon
Avon and Somerset Police Devon and Cornwall Police Devon Partnership NHS Trust +3 more
Concerns summary A lack of mechanisms for transferring serious crime suspects in police custody to mental health facilities and insufficient understanding of autistic prisoners' needs pose significant risks.
Jason Pendlebury
All Responded
2020-0069 12 Mar 2020 Manchester North
Greater Manchester Police North West Ambulance Service
Concerns summary Critical communication breakdowns and lack of information sharing between police, ambulance services, GPs, and mental health professionals repeatedly led to inadequate risk assessments and missed opportunities for mental health intervention.
Roy Campbell
All Responded
2020-0059 9 Mar 2020 Worcestershire
Worcestershire Health and Care NHS Trust
Concerns summary Inadequate systems to prevent detained patients from absconding included a flawed visitor tracking system and environmental checks not properly implemented or enshrined in policy with mandatory staff training.
Shaun Turner
All Responded
2020-0050 3 Mar 2020 Manchester South
Department of Health and Social Care
Concerns summary Significant delays in accessing mental health services and support, along with the adverse psychological impact on patients of missed contact attempts, raised serious concerns.
Sophie Boothe
All Responded
2020-0142 2 Mar 2020 Hampshire (Central)
Berkshire Healthcare NHS Foundation Tru…
Concerns summary Poor communication and insufficient exploration of information from foreign jurisdictions, specifically misunderstanding critical medical terms, led to inadequate mental health assessment and referral downgrading.
Wayne Millett
All Responded
2020-0031 18 Feb 2020 Manchester South
Priory Group
Concerns summary The care provider's investigation lacked critical analysis, revealing an inability to learn from serious incidents, inconsistent staff adherence to care plans, and failure to review medication side-effect monitoring protocols.
Joseph Gingell
All Responded
2020-0027 17 Feb 2020 Essex
NHS England
Concerns summary Permitting "self-certification" for medication without checks, allowing abuse by vulnerable individuals, and not involving the GP removes crucial safeguards, contributing to toxic drug interactions.
Gemma Azhar
All Responded
2020-0026 11 Feb 2020 West Sussex
Sussex Community NHS Foundation Trust
Concerns summary Repeated mental health appointment cancellations by administrators, without clinical follow-up, left patients at risk. The "formal position" for duty worker contact after cancellations lacks proper policy, training, or consistent application.
Adrian Ashford
All Responded
2020-0054 7 Feb 2020 London Inner South
Queen Elizabeth Hospital
Concerns summary There was no systematic process for recording patient weights to identify critical changes, and a consultant failed to recognise serious GI bleed risks or make appropriate specialist referrals for a deteriorating patient.
David Clark
All Responded
2020-0023 6 Feb 2020 Lancashire & Blackburn with Darwen
Lancashire Care NHS Trust
Concerns summary Deficiencies in documentation, failure to follow AWOL procedures, inadequate staff handovers, and a general lack of training on policy and procedure created significant safety risks.
Thiago Araujo
All Responded
2021-0132 29 Jan 2020 East London
Royal Mail Camden and Islington NHS Foundation Tru… Department of Health and Social Care +2 more
Concerns summary The provided concerns text is incomplete, preventing a proper summary of the identified safety issues.
Helen Sheath
All Responded
2020-0107 27 Jan 2020 Bedfordshire and Luton
Association of Ambulance Chief Executiv… Emergency Call Prioritisation Advisory … National Association of Ambulance Medic…
Concerns summary Ambulance services incorrectly coded an initial emergency call for a suicidal patient, delaying the dispatch of appropriate urgent response teams and potentially altering the outcome.
Jason Devoti
All Responded
2020-0017 21 Jan 2020 Worcestershire
West Midlands Police
Concerns summary West Midlands Police failed to address numerous P2 incident logs due to overwhelming backlogs, insufficient officers, and inadequate control room staffing, leading to significant response delays.
Miles Naylor
All Responded
2020-0005 10 Jan 2020 West Yorkshire (West)
Bradford District Care NHS Trust
Concerns summary Concerns were raised about the management of ligature risks from personal items and the unsafe design of ward doors, specifically regarding access to hinge pins, at a mental health facility.
Jacob Bates
All Responded
2019-0456 31 Dec 2019 Derby & Derbyshire
Department for Education
Concerns summary Vulnerable 16-18 year olds are placed in unregulated care settings lacking statutory oversight, leaving local authorities unable to adequately assess provider competency or safety due to resource constraints.
Joanna Orpin
All Responded
2019-0457 31 Dec 2019 Isle of Wight
Isle of Wight Council National Trust on the Isle of Wight
Concerns summary Samaritans signs, previously present at Culver Cliff, have been removed, despite numerous individuals being found in mental distress there monthly and repeated recommendations for their reinstallation being ignored.
David Fowler
All Responded
2019-0450 20 Dec 2019 Manchester (West)
TRU
Concerns summary The patient's family was not informed or invited to an MDT meeting before his Mental Health Act section was lifted. Staff lacked clarity on who was responsible for family communication, and no formal policy was in place.
Samantha Higgins
All Responded
2019-0483 13 Dec 2019 London (East)
North East London Hospital Trust
Concerns summary A patient remained under a "brief intervention" team for an extended period without an overarching care plan or key-worker, and faced excessive delays (17 months) in accessing crucial psychotherapy treatment.
Callie Lewis
All Responded
2019-0414 3 Dec 2019 Kent (Central and South East)
Department for Culture, Media and Sport
Concerns summary An online suicide forum provided dangerous advice, enabling individuals to mislead mental health professionals and perfect suicide methods, thus frustrating necessary assessments and interventions.
Charlotte Grace
All Responded
2019-0402 29 Oct 2019 Cumbria
Cumbria, Northumberland, Tyne and Wear …
Concerns summary Patients are discharged from mental health care without routine involvement from receiving care agencies or supportive family/friends, a systemic failure repeatedly identified as a risk.
Lauren Finch
All Responded
2019-0506 22 Oct 2019 Manchester West
North West Boroughs Healthcare NHS Foun…
Concerns summary Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record entries, failing to provide timely, vital information for subsequent shifts.
Matthew Williamson
All Responded
2019-0349 15 Oct 2019 London (West)
West London Mental Health Trust
Concerns summary Carers and family lack opportunities to provide vital information to mental health teams, and unclear inter-provider communication creates difficulty navigating treatment pathways for patients.
Abdeslam Benelghazi
All Responded
2019-0337 10 Oct 2019 Avon
Department of Health and Social Care
Concerns summary Concurrent prescribing of methadone with multiple sedative medications, particularly clonazepam, created a dangerous combined effect of central nervous system and respiratory depression, significantly increasing the risk of sudden death.