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).

Response Status
Responded 492 No Response 9 Historic 126 Pending 5
AI Classification
Action Taken 45%
Action Planned 37%
Noted 17%
Disputed 0%
Based on 803 classified responses
Reports by Quarter
PFD Reports
636 results
Timothy Steele
Historic (No Identified Response)
2021-0076 15 Mar 2021 City of Brighton and Hove
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary) Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).
Paula Speirs
All Responded
2021-0064 4 Mar 2021 Inner North London
Weymouth Street Hospital
Concerns summary (AI summary) There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.
Action Taken (AI summary) Phoenix Hospital Group has reviewed and revised policies/procedures at Weymouth Street Hospital, conducted root cause analysis meetings, scheduled a Managing a Deteriorating Patient workshop, and is highlighting the Coroner's concerns to nurses through regular briefings and a final reflection and learning session.
Grazyna Walczak
All Responded
2021-0063 4 Mar 2021 Inner North London
St Pancras Hospital
Concerns summary (AI summary) The iCope service failed to involve family in mental health assessments, and a critical 72-hour investigation report was severely delayed, hindering urgent learning.
Action Planned (AI summary) The iCope service has reviewed its policy on contact with clients’ families and is implementing a new system reporting process to enable easier reporting and monitoring of 72-hour reports, including a training programme for divisional staff to support the implementation of the new system.
Steven Stout
All Responded
2021-0059 3 Mar 2021 East London
Department of Health and Social Care North East London NHS Foundation Trust
Concerns summary (AI summary) There were failures in accurately recording and filing important medical records, including discharge decisions and risk assessments, and ensuring effective patient referral to community mental health teams.
Action Planned (AI summary) North East London NHS Foundation Trust will provide record keeping training to staff, develop and implement a discharge checklist, audit implementation of the checklist, update the HTT service operational procedure, and update the Trust’s Clinical Handover of Care and Discharge Policy. The Department of Health and Social Care acknowledges concerns and highlights the NHS Long Term Plan and the COVID-19 mental health and wellbeing recovery action plan, which includes funding to expand community mental health services and support suicide prevention work.
Sarah Smith
Historic (No Identified Response)
2021-0050 22 Feb 2021 Hampshire, Portsmouth and Southampton
Institute for Health and Care Excellence National General Medical Council Southern Health NHS Foundation Trust of…
Concerns summary (AI summary) Mental health clinicians failed to consider or routinely monitor the significant impact of hormonal changes as a contributory factor to depression in peri-menopausal women.
Jaden Francois-Espirit
All Responded
2021-0048 22 Feb 2021 Inner North London
London Fire Brigade
Concerns summary (AI summary) The London Fire Brigade failed to recognise deteriorating mental well-being in a firefighter, missing subtle signs and not exploring his refusal of offered support.
Action Taken (AI summary) LFB accepted all 24 recommendations in the investigation report following the death of Jaden Francois-Esprit, and created an action plan, extended to include the coroner's concerns, with a total of 32 actions. As of June 10 2021, nine of these actions have been completed across 11 broad areas including recruitment, training, support and culture.
Philippa Day
All Responded
2021-0043 12 Feb 2021 Nottingham and Nottinghamshire
Capita Department for Work and Pensions
Concerns summary (AI summary) DWP call handlers lacked training for mentally ill claimants, and brief, inaccurate call records hindered decision-making. The assessment process was inflexible, preventing correction of errors or flexible appointment management.
Action Planned (AI summary) The DWP has already introduced a highly visible "watermark" in the PIP computer system showing if a customer has additional support needs. Script changes to better support vulnerable claimants will go live by the end of May 2021, and strengthened wording regarding DLA will be introduced by early May 2021. Capita is pausing the issue of appointment letters during Change of Assessment or Further Review periods. They are also working with DWP to review the tone and language in written communications. Full implementation of the changes will be in place by 30 September 2021.
Robert Hardy
All Responded
2021-0039 11 Feb 2021 Greater Manchester South
Greater Manchester Police
Concerns summary (AI summary) Police failed to record an assault as a crime, preventing the provision of appropriate victim support and signposting for a vulnerable individual with known vulnerabilities.
Action Taken (AI summary) Greater Manchester Police has established a central Crime Recording and Resolution Unit (CRRU) to improve crime recording accuracy, in response to concerns raised. They are also implementing the national THRIVE model and the 'Making a Difference System' to improve identification of and response to vulnerabilities and to improve victim support.
Carole Mitchell
All Responded
2021-0037 11 Feb 2021 Greater Manchester South
Department of Health and Social Care Greater Manchester Health and Social Ca…
Concerns summary (AI summary) Significant regional and national backlogs for mental health therapies and limited bed capacity caused care delays and distant placements. Health professionals also misunderstood patient confidentiality, hindering crucial information gathering from families.
Action Planned (AI summary) Learning from the case will be presented to the Greater Manchester Quality Board and shared with commissioners of services. The partnership is also working to improve bed capacity and information sharing, and enhance digital capabilities as part of its mental health strategy 2021-24. The Department is providing targeted funding to local areas for suicide prevention and bereavement support, aiming for every area to receive funding by 2023/24. The Zero Suicide Alliance is developing guidance for frontline staff on information sharing, with publication due shortly.
Michael Dobson
All Responded
2021-0035 11 Feb 2021 Staffordshire South
HMP Dovegate
Concerns summary (AI summary) Limited staff availability post-prison lockdown means essential maintenance, like electricity supply issues, is delayed until the next day. This creates a potential for prisoners to self-harm.
Action Taken (AI summary) HMP Dovegate has ensured there is an on-call facilities maintenance officer available to remedy electricity faults in cells during out-of-hours periods. Duty Managers have been reminded of their responsibility to contact the on-call officer and that electricity should not be left inactive for any period of time.
Valeria Biggs
Historic (No Identified Response)
2021-0034 11 Feb 2021 Inner West London
Acute Mental Health Services, West Lond…
Concerns summary (AI summary) Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.
Lisa Thompson
All Responded
2021-0171 10 Feb 2021 Oxfordshire
Oxford Health NHS Trust
Concerns summary (AI summary) Mental health care plans and risk assessments were not updated with critical information regarding the patient's multiple medication overdoses, including a doctor's warning about the severity.
Action Planned (AI summary) The Littlemore Mental Health Centre will include areas of improvement relating to this incident within a thematic review including ensuring family members are included in care and treatment and ensuring risk formulation and suicide risk assessment are enhanced and embedded in safety planning for patients. Trust audits will also include looking at the quality of risk assessments and care plans and safety planning questions.
Jason O’Rourke
All Responded
2021-0032 10 Feb 2021 Inner South London
HMP Belmarsh and HMPS
Concerns summary (AI summary) HMP Belmarsh's immediate needs form inadequately assesses self-harm risk for new prisoners without existing care plans. The nightly roll check system lacks robust auditing, risking missed checks and compromising prisoner safety.
Action Taken (AI summary) HMP Belmarsh has updated its 'immediate needs' form for new prisoners to provide clearer guidance to staff on actions to take regarding suicide/self-harm risks, including communication with healthcare and documentation. The LTHSE safety team will also be visiting to identify further opportunities for improvement.
James Taylor
Partially Responded
2020-0300 East London
Continuing Care Continuing Care, Redbridge Clinical Com… Redbridge Clinical Commissioning Group …
Concerns summary (AI summary) Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.
Noted (AI summary) The Royal College of General Practitioners explained the current system for transferring GP records, supporting electronic transfer (GP2GP) for its advantages. They clarified that the responsibility for the transfer system lies with Primary Care Support England, not the RCGP itself. Barking, Dagenham, Havering and Redbridge CCG and NELFT have implemented changes to the Psychological Therapies service, including updating standard operating procedures, increasing service capacity, and reviewing panel protocols to manage risks associated with waiting lists. They are also planning a formal service review and considering further investment.
Steven Cooke
Historic (No Identified Response)
2020-0302 30 Dec 2020 Stoke-on-Trent and North Staffordshire Coroner’s Court
NHS England
Concerns summary (AI summary) There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.
Tina Murray
All Responded
2020-0296 22 Dec 2020 Blackpool and Fylde
Belgravia Care Home Ltd
Concerns summary (AI summary) Plastic bags, which posed a risk to the deceased, appear to have been accessible within Belgravia Care Home.
Action Taken (AI summary) Belgravia Care Home removed plastic bags from resident bedrooms, safely disposed of shopping bags, locked away all other bags, and implemented robust risk assessments for residents at risk of suicidal tendencies.
Jennifer Spencer
All Responded
2021-0010 18 Dec 2020 East Sussex
NHS England
Concerns summary (AI summary) Mental health professionals lack awareness of "Shamanic" hallucinogenic drugs, leading to inadequate assessment and treatment for psychosis caused or exacerbated by their use.
Action Planned (AI summary) NHS England is providing targeted funding to STPs for multi-agency suicide prevention plans. The South East region suicide prevention lead is working to raise awareness regarding ‘shamanic hallucinogenic drugs’ and NHSE/I will share any learning generated by the South East regional team nationally.
Andrew Gibbins
All Responded
2020-0290 17 Dec 2020 Suffolk
West Suffolk Hospital and The Wedgewood…
Concerns summary (AI summary) A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.
Action Taken (AI summary) The Trusts have commenced monthly meetings between the head of mental health and the lead nurse, and reviewed the handover process, incorporating SBAR documentation into the WSFT risk assessment. The acute hospital missing person’s policy has been reviewed and deemed fit for purpose in January 2021. Hellesdon Hospital reports that they have established regular interface meetings with the West Suffolk Hospital to improve communication and have formalized these meetings with agreed actions and minutes for governance purposes.
Christopher Swain
All Responded
2020-0284 14 Dec 2020 West Sussex
Sussex Partnership NHS Foundation Trust
Concerns summary (AI summary) Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.
Noted (AI summary) The Trust acknowledges failings in care and outlines previous actions taken following the death, including an internal investigation and sharing of learning. The Trust states that policies for Section 17 leave were in place, but not followed, and weekly audits are now conducted to ensure compliance.
Claire Lilley
All Responded
2020-0297 11 Dec 2020 Inner London South
Oxleas NHS Trust
Concerns summary (AI summary) Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Action Planned (AI summary) Oxleas NHS Foundation Trust will require consistent recording of service users' and carers' feedback in the MDT template, make risk decisions at every MDT meeting, assign responsibility for updating risk assessments after each MDT, and update the Clinical Risk Assessment and Management Policy accordingly. The Medical Director and Director of Nursing will communicate these standards to all clinicians, facilitated by a team approach to risk management led by Matrons.
Katy Samuels
All Responded
2020-0282 11 Dec 2020 Coventry
Chief Executive and Mental Health lead …
Concerns summary (AI summary) The Section 17 Leave Policy lacked clear guidance on escorted leave and escort identity verification, enabling a detained patient to leave unobserved, return intoxicated, and subsequently self-harm.
Action Taken (AI summary) Coventry and Warwickshire Partnership NHS Trust has amended its Section 17 Leave Policy to ensure patients are collected from and returned to the ward by identified individuals. The Trust is also implementing structured handover meetings at shift changes and introducing competency-based training for staff.
Rory Attwood
All Responded
2021-0086 10 Dec 2020 Gwent
Aneurin Bevan University Health Board
Concerns summary (AI summary) The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Action Taken (AI summary) Aneurin Bevan University Health Board has reviewed its practices regarding GP involvement in Serious Incident Reviews and devised a process and pro forma to ensure GPs are invited to participate. The Mental Health and Learning Disabilities Division is also reviewing processes to ensure third sector and other organisations' involvement is recorded sooner.
Kimberley Smith
All Responded
2020-0279 9 Dec 2020 Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary) The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Action Taken (AI summary) The Trust has developed guidance regarding alcohol detoxification for people admitted to inpatient wards and are developing new guidelines for managing people with Alcohol Use Disorders (AuDs). They have also completed a retrospective baseline audit and will complete a second audit to check for improvements.
Roy Curtis
All Responded
2020-0272 4 Dec 2020 Milton Keynes
Milton Keynes Council and Social Servic…
Concerns summary (AI summary) Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Action Taken (AI summary) Milton Keynes Council has employed a link social worker to work with the acute mental health hospital ward to coordinate social care assessments before discharge. They have also reviewed Autism training to include awareness of suicidality and risks, and will make home visits if contact is not made by phone, letter or email, escalating to the police for welfare checks if necessary.
Andrew Westlake
All Responded
2020-0268 3 Dec 2020 County Durham and Darlington
Jet2.com Ltd and Civil Aviation Authori…
Concerns summary (AI summary) Airline staff lacked policy and training for identifying and safeguarding mentally unwell, vulnerable passengers, leading to disembarkation without support in a foreign country.
Action Planned (AI summary) Jet2.com has updated its Ground Handling Manual to include procedures for supporting vulnerable passengers, including contacting family/friends, embassies, or other services. Training will be updated using the case as a study, and the CAA has approved the amended procedures. The Civil Aviation Authority (CAA) will explore how to define vulnerable consumers, propose improvements to their treatment in the UK aviation industry, and increase engagement with industry. The CAA Executive will receive a report in Q1 2021 and review progress regularly.