Mental Health related deaths

PFD Category
Reports: 630 Areas: 69 Earliest: Aug 2013 Latest: 20 Mar 2026

77% response rate (above 62% average). 62% 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 9
AI Classification
Action Taken 62%
Action Planned 21%
Noted 13%
Disputed 4%
Based on 400 classified responses
Reports by Quarter
PFD Reports
630 results
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
Zsolt Kirjak
Response Pending
2022-0197 Inner West London
Central and North West London NHS Found… Imperial College health Care NHS Trust … Portland Practice
Concerns summary The patient received an incomplete psychiatric and risk assessment that failed to appraise his serious suicide risk factors and previous self-harm attempts. His wife was not given opportunity to contribute to assessments.
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 High Street Surgery conducted an audit of all patients prescribed Zopiclone, contacted all current patients for a structured medication review, and updated its Z-Drug Protocol. The surgery has also co
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 NHS Suffolk and North East Essex has provided additional funding to increase NSFT service capacity, established a new clinical leadership post, and repurposed the First Response Service (FRS) to trans
Shona Campbell
Response Pending
2022-0202 Manchester City
Greater Manchester Mental Health NHS Fo… Alternative Futures Group Safety Matters (Legal) Limited +1 more
Concerns summary Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.