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
Polly Carpenter
All Responded
2014-0469 28 Oct 2014 Exeter & Great Devon
Devon Partnership NHS Trust
Concerns summary The hospital lacked clear, auditable records for patient risk assessments and observation levels on RIO, leading to staff being unaware of risks and hindering accountability. The "Named Nurse system" was also unclear.
Lucy Moffatt
All Responded
2014-0261 10 Jun 2014 South Yorkshire (West)
Care Quality Commission Department of Health and Social Care
Concerns summary Window restraints were found to be misleadingly insecure, easily defeated, and establishments lacked proper key restriction, further compounded by CQC inspectors' unawareness of a critical Department of Health alert.
Adrian Cowan
All Responded
2014-0111 7 Feb 2014 London (North)
North London Forensic Service
Concerns summary The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.
Amanda Vickers
All Responded
2014-0052 3 Feb 2014 Cumbria (North & West)
NHS Cumbria Clinical Commissioning Group
Concerns summary A severe shortage of specialist crisis home beds, with no clear availability, contributed to a patient's death while awaiting admission, highlighting inadequate commissioning by the CCG.
Julie Ann Camm
All Responded
2014-0023 17 Jan 2014 West Yorkshire (East)
Leeds City Council
Concerns summary A vulnerable tenant's property lacked smoke alarms because the housing association's policy only encouraged fire safety checks, failing to ensure installation and increasing the risk of death from fire.
Action taken summary Leeds City Council's Housing Leeds has updated its Electrical Specification to require hard-wired smoke detection during any major electrical works. They are installing hard-wired smoke detectors in 3
Simon Sankey
All Responded
2013-0361-wp24075 27 Dec 2013 Manchester (West)
5 Boroughs Partnership NHS Foundation T…
Felix Cembrowicz
All Responded
2013-0204 12 Dec 2013 Avon
Avon and Wiltshire Mental Health Partne…
Concerns summary The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Action taken summary The Trust has updated its initial assessment/admission process to require staff to check for historic relapse management plans and other key documents (CPA, risk assessments) from previous electronic
John Walker
All Responded
2013-0213 21 Aug 2013 West Sussex
Sussex Partnership NHS Trust
Concerns summary Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Action taken summary The Trust has revised clinical documentation for risk care planning and conducts regular audits to ensure standards are met. They have also altered fences throughout Langley Green Hospital to make it
James Taylor
All Responded
2020-0300 East London
Continuing Care Redbridge Clinical Commissioning Group …
Concerns summary Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.
Action taken summary Barking Dagenham Havering and Redbridge CCG, in collaboration with NELFT, has implemented changes to psychological therapies service procedures, increased service capacity, and updated panel protocols
Mina Topley-Bird
All Responded
2021-0100 County Durham and Darlington
West Park Hospital Department of Health and Social Care
Concerns summary Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.
Action taken summary Tees, Esk and Wear Valleys NHS Foundation Trust immediately implemented a checklist for Accident and Emergency patients from outside the area to ensure information gathering and sharing. They are also
Ian Cockfield
All Responded
2022-0158 East London
Department of Health and Social Care an…
Concerns summary The concerns text refers to a narrative conclusion not provided, therefore no specific issues can be summarised from the given text.
Action taken summary The Department of Health and Social Care notes existing NICE guidelines for falls risk assessment and that NICE is updating this guidance, due 2024, to include patients under 65 with mental health pro
Louise Allen
All Responded
2022-0159 East London
North East London NHS Foundation Trust …
Concerns summary An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care co-ordinators facing high caseloads and staff turnover.
Action taken summary The Trust conducted a pay review in July 2021, upgrading all Band 5 Nurses to Band 6, and gave a £1000 payment to Band 6 Care Coordinators in October 2021. They have also agreed to recruit eight addit
Samuel Gomm
All Responded
2022-0163 South Wales Central
Powys County Council Powys Teaching Health Board
Concerns summary The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing new users to underestimate risk and miss referral opportunities.
Action taken summary Powys County Council and Powys Teaching Health Board have fully implemented the WARRN risk assessment tool in Community Mental Health Teams, with full integration into inpatient Electronic Patient Rec
Andrew Nixon
All Responded
2022-0165 Dorset
Somerset NHS Foundation Trust
Concerns summary Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear criteria for conducting a Carer's Assessment, limiting protective factors.
Action taken summary NHS Somerset has issued new staff briefings and posters on consent and confidentiality, updated clinical risk training content, and established a policy requiring co-produced safety plans shared with
Keith Nottle
All Responded
2022-0189 Nottingham City and Nottinghamshire
Nottinghamshire Healthcare Trust and Tu…
Concerns summary Mental health crisis triage bypasses specialist assessment, relying on telephone workers' limited judgment. There was a lack of care coordination for complex patients and unclear multi-disciplinary team decision-making.
Action taken summary NHS Nottinghamshire Healthcare is undertaking a clinical records audit and a service review during September and October 2022 to ensure practice aligns with the agreed Standard Operating Procedure. Fo
Khalid Yousef
All Responded
2022-0193 Birmingham and Solihull
Birmingham and Solihull Mental Health West Midlands Police Home Office +1 more
Concerns summary Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.
Action taken summary West Midlands Police has instructed the creation of a formal escalation process for Liaison and Diversion (L&D) decisions, a review of mental health training for custody officers/staff, and the provis
Alun Davies
All Responded
2022-0196 Hampshire, Portsmouth and Southampton
South Western Railway and BTP Fatal Inv…
Concerns summary Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. Previous safety recommendations remain unaddressed, and public welfare announcements are lacking.
Action taken summary South Western Railway has rejected increasing staffing levels, RCO patrols, and 24/7 CCTV surveillance at Portchester Station, stating existing measures are adequate. They have already installed tresp
Michael Vince
All Responded
2022-0198 East London
North East London Foundation Trust and …
Concerns summary A patient was prescribed a short-term medication for 20 years against guidelines without meaningful review or monitoring of PRN use, and dependence evidence was not shared between health trusts.
Action taken summary North East London Foundation Trust (NELFT) arranged a wider learning review led by its pharmacy department and developed an action plan in response to the inquest findings. NELFT has updated its pract
Paul Meadows
All Responded
2022-0201 Suffolk
Ipswich and East Suffolk Clinical Commi… Department of Health and Social Care
Concerns summary Systemic issues due to resource pressures and underfunding led to inconsistent triage, inadequate risk assessments, and safety planning failures within the First Response Service nationally.
Action taken summary The Department of Health and Social Care is overseeing specific actions at the Norfolk & Suffolk NHS Foundation Trust, including a CQC warning notice, an NHS England Recovery Support Programme, and a