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
419 resultsChristopher Vickers
All Responded
2024-0259
29 Feb 2024
Gateshead and South Tyneside
Cumbria, Northumberland, Tyne and Wear …
South Tyneside Council
Concerns summary (AI summary)
There were multiple missed opportunities to coordinate care through multi-disciplinary meetings and to make safeguarding referrals despite the deceased's known escalating risks.
Action Taken
(AI summary)
The Trust has implemented changes to ensure relevant safeguarding referrals and multi-agency meetings are convened, including changes to MDT processes and safeguarding as a standard agenda item; also improved engagement with families and carers. Supervision processes have been updated and audits are taking place. South Tyneside Council expressed condolences and stated that changes had already been made and that they had further re-evaluated internal policies and procedures. They detailed actions taken prior to the inquest including multi-agency working improvements and updated safeguarding procedures; actions being taken now including additional training and policy revisions; and actions planned including Mental Health Act training and a mandatory safeguarding module for frontline practitioners.
Jamie Pilkington
All Responded
2024-0101
22 Feb 2024
Staffordshire and Stoke on Trent
Midlands Partnership Foundation Trust
Concerns summary (AI summary)
Mental health teams repeatedly failed to complete suicide risk assessments and thoroughly explore the deceased's suicidal thoughts, research into methods, or support networks. No system changes were assured to prevent future omissions.
Action Planned
(AI summary)
MPFT is rolling out a three-year suicide prevention plan, including suicide awareness training, safety planning, family engagement, and real-time suicide surveillance and learning from deaths process.
Roberto Bottello
All Responded
2024-0087
16 Feb 2024
Inner West London
Central and North West London NHS Found…
Metropolitan Police Service
NHS England
Concerns summary (AI summary)
Failures in mental health service follow-up and assessment, alongside significant delays in Mental Health Act assessment at hospital, despite clear signs of acute psychosis.
Action Planned
(AI summary)
NHS England colleagues will be asked to share the learnings from the case within their health and care systems, and will consider whether any further action needs to be taken regarding the concerns. CNWL has implemented measures including establishing dedicated s136 hubs, improving communication, and maintaining safer staffing levels, and SPA no longer manages calls from the Police or supports locating Health Based Place of Safety (HBPOS) suites. All HBPOS suites across London update the SMART Tool in real time. The Metropolitan Police Service reminds recruit police officers about airwave etiquette including the phonetic alphabet and expects them to demonstrate competence through role play activities; the training material is being amended to emphasise the requirement to use the phonetic alphabet to conduct name checks.
Nazerine Anderson
All Responded
2024-0080
13 Feb 2024
Rutland and North Leicestershire
Department for Work and Pensions
Concerns summary (AI summary)
DWP staff failed to record and act upon a customer's known vulnerability and requests for communication through her daughter, indicating inadequate training and use of existing support tools.
Action Planned
(AI summary)
DWP will deliver training sessions to 170 Performance Management team members by the end of June 2024, focusing on identifying and supporting vulnerable customers, including prioritizing the use of the additional support tab in UC system. Upskilling sessions for colleagues who worked on the case are planned. Appointeeship process is also being reviewed with upskilling and system upgrades already concluded.
Larry Spriggs
All Responded
2024-0104
22 Dec 2023
Surrey
Surrey and Boarders Partnership NHS Fou…
Concerns summary (AI summary)
The coroner notes a lack of evidence of cultural change in patient care and treatment, as well as concerns regarding inpatient risk assessment, information passage between staff, and intermittent observation management at Farnham Road Hospital.
Action Taken
(AI summary)
The Trust has launched a new five-year strategy focused on high-quality care, an inpatient improvement plan for safety and quality improvements, and introduced the Supportive Observations Audit Tool, with a digital solution being tested for recording supportive observations. They are also leading a national work stream on workforce and training for therapeutic observations.
Ryan Evans
All Responded
2024-0005
20 Dec 2023
Hampshire, Portsmouth and Southampton
Frimley Health NHS Foundation Trust
Surrey and Borders Partnership NHS Foun…
Concerns summary (AI summary)
Hospital staff failed to conduct a mental health assessment for a patient with obvious self-harm and suicidal ideation, contradicting NICE guidelines. Critical suicidal ideation was also not adequately recorded.
Action Planned
(AI summary)
The Trust is working with other acute NHS Trusts within Surrey as part of the Surrey Heartlands Mind & Body Programme. A mental health skills module for nurses working at Frimley began last year, and there is space for 30 students for the next cohort starting in March 2024. Frimley Health has updated Emergency Department Triage processes, introduced a Mental Health Assessment form, and developed a Mental Health Strategy Group. They also hold monthly meetings with Psychiatric Liaison services and Surrey Police to discuss practical points and evolving issues.
Charlene Roberts
All Responded
2023-0516
8 Dec 2023
Manchester North
Greater Manchester Health and Social Ca…
Medicines and Healthcare Products Regul…
NHS England
+1 more
Concerns summary (AI summary)
The report identifies a lack of treatment options for the deceased's cyclizine addiction and eating disorder, with multiple rejections from specialist services and no clear plan for managing her complex needs.
Action Planned
(AI summary)
NHS England is developing a joint action plan with the Department of Health and Social Care to improve the provision of mental health treatment for people with drug dependence, to be published and implemented later in 2024. The MHRA will consider the case and wider evidence regarding the misuse of cyclizine and determine whether the current risk minimisation measures are sufficient, communicating further action to healthcare professionals and patients if required. A GM level review of phlebotomy provision has been undertaken recently which has identified the variation in provision and sets out the intention to improve the consistency of offer to patients across Greater Manchester. This is also a priority deliverable of the Greater Manchester Primary Care Blueprint. The Royal College of Psychiatrists will communicate the potential risk of cyclizine addiction to its members through newsletters and faculty communications, and will raise the issue with mental health organisations and those responsible for the mental health system.
Zulfiqar Hussain
All Responded
2023-0476
24 Nov 2023
Manchester North
Croft Shifa Health Centre
Concerns summary (AI summary)
Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.
Action Taken
(AI summary)
The practice reviewed its document management in Nov 2021 and updated its Document Management Policy to include suspected cancer referrals, learning disabilities, mental health/depression, safeguarding notifications, addiction and patients on Gold Standard Framework to be sent to GPs. An alert was added to Mr Hussain's record alerting clinicians to potential medication misuse.
Madeleine Savory
All Responded
2023-0452
15 Nov 2023
Suffolk
NHS England
Concerns summary (AI summary)
There is a national shortage of Tier 4 beds in paediatric mental health facilities, delaying timely access to crucial care for children in need.
Noted
(AI summary)
NHS England is implementing improvements to the CYMPH inpatient pathway, aiming to reduce out-of-area placements and move towards community-based care; they are also developing a national admission protocol for children and young people with multi-agency partners. The Department of Health and Social Care acknowledges the concerns and notes NHS England's response and approach to reduce reliance on inpatient mental health beds, moving towards community-based care.
Mark McKessy
All Responded
2023-0377
9 Oct 2023
Manchester South
One Stockport Health and Care Board
Concerns summary (AI summary)
Poor inter-agency communication and a failure to recognise complex health and learning disability needs prevented coordinated care, leaving a vulnerable individual without adequate risk reduction measures.
Action Planned
(AI summary)
Stockport Integrated Care Partnership acknowledges the concerns and highlights that a joint learning event is planned for January 2024 to strengthen information sharing and improve practice related to supporting people with learning disabilities. They also plan to engage with the family to share experiences.
Shaun Houghton
All Responded
2023-0350
25 Sep 2023
Manchester West
Greater Manchester Mental Health NHS Fo…
Concerns summary (AI summary)
A junior doctor allowed a high-risk patient with impulsivity and suicidal intent to self-discharge against medical advice, without consulting senior clinicians, raising concerns about the decision-making process.
Action Planned
(AI summary)
GMMH is developing a Standard Operating Procedure (SOP) for self-discharge against medical advice, including a checklist for ward staff. The SOP will be submitted for ratification in January 2024 and disseminated to staff by February 2024.
Melvyn Blount
All Responded
2023-0345
21 Sep 2023
Derby and Derbyshire
Lister House Oakwood
Concerns summary (AI summary)
A lack of clear policy for communicating drug alerts when a GP prescribes for a patient not seen directly by them, but by a non-prescriber, risks patients missing crucial medication information.
Action Taken
(AI summary)
The practice has implemented several reviews and changes to prescribing practices and supervision, including a new policy and flow chart for drug alerts, improved documentation, a new consultation booking system and training. An educational event was held to discuss recognition and management of psychotic depression.
Lauren Bridges
All Responded
2023-0438
19 Sep 2023
Manchester South
Department of Health and Social Care
NHS England
Concerns summary (AI summary)
Underfunding for local mental health beds and reliance on independent providers caused delayed discharges for out-of-area patients. Fragmented IT systems and inconsistent processes created significant communication failures.
Action Taken
(AI summary)
Dorset HealthCare has made changes to the Hospital Overview document, enhanced the daily Hospital Overview situation report, improved communication between Clinical Site Managers and introduced monthly audits to ensure standards are met in patients receiving out of area care. NHS England reports on actions taken by Dorset Healthcare University NHS Foundation Trust: improvement to data and oversight, appointment of an out of area co-ordinator and a programme of quality assurance of providers used by the Trust. They have also secured planning permission to rebuild some of their mental health inpatient facilities and increase the availability of PICU for adults and younger people. The Department of Health and Social Care notes actions taken by NHS England and Dorset Healthcare University NHS Foundation Trust. They are investing in community mental health care and have published statutory guidance for discharge from all mental health inpatient settings.
Odichukwumma Igweani
All Responded
2023-0296
16 Aug 2023
Milton Keynes
BLMK Integrated Care Board
North West London NHS Foundation Trust
Red House Surgery
Concerns summary (AI summary)
A critical lack of clear information and guidance prevented an individual from accessing urgent out-of-hours mental health assessment and care, despite their obvious deteriorating condition.
Noted
(AI summary)
The ICB will work with primary care practices to ensure patients declined registration receive details on how to find and register with a GP and ensure practices are aware of the mental health single point of access. They will also work with CNWL to ensure mental health crisis information is available in surgery waiting areas and continue to work with 111 providers on the dedicated process for mental health due in Spring 2024. Red House Surgery states it was unable to register the patient due to their address being outside the practice catchment area, and this is practice policy. They assert they provided the mother with the number for the crisis centre, which is practice policy for anyone raising a mental health concern who cannot access a GP. CNWL will discuss the case in a Care Quality Improvement Forum meeting, cascade a learning leaflet to local GPs via the Primary Care Network (PCN) alliance, and supply posters to GP surgeries with information on how to access mental health services via the ED at MKUH. Nationally, NHS England are working with NHS 111 to create a dedicated process to access MH services due in April 2024.
Kenneth Rippon
All Responded
2023-0268
19 Jul 2023
County Durham and Darlington
Care Quality Commission
Tees, Esk and Wear Valley NHS Foundatio…
Concerns summary (AI summary)
Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Action Taken
(AI summary)
Tees, Esk and Wear Valleys NHS Foundation Trust has contracted additional expert capacity in incident reviews to actively address delays, allocating 41 reviews. They have increased capacity in the mortality team, provided additional training, and are externally reviewing a specific case. Tees, Esk and Wear Valleys NHS FT has contracted in additional expert capacity in incident reviews, increased internal capacity, and reviewed all incidents to ensure they have met Duty of Candour. They have also modified documentation, reviewed report templates, and are utilising standard operating procedures. The CQC has monitored the trust’s progress with reducing the backlog of serious incidents and preventing reoccurrence. They state the trust provided information showing the backlog had reduced, with a target date of December 2023 for completion of all historical investigation reports, and a revised process is in place to prevent reoccurrence of this backlog.
Kaye McCoy
All Responded
2023-0221
30 Jun 2023
Gwent
Aneurin Bevan University Health Board
Concerns summary (AI summary)
The health board failed to provide a strategy for family engagement and 24-hour crisis support, despite national recommendations, suggesting these crucial guidelines are not fully integrated into practice.
Action Planned
(AI summary)
The Health Board is considering the findings and recommendations of a 6-month pilot extending the hours of the Community Mental Health Team, exploring other alternatives for crisis support, and will continue to audit the use of the current pathway by the older adult population.
George Griffiths
All Responded
2023-0223
28 Jun 2023
Herefordshire
Wye Valley NHS Trust
Concerns summary (AI summary)
A significant pressure sore developed during the patient's lengthy and complicated hospital admission, contributing to death and raising concerns about care quality in the elderly care ward.
Action Taken
(AI summary)
The Trust has introduced a senior nurse care review in the ED, developed and piloted a local competency package for pressure area care (starting with the Frailty service), refreshed Tissue Viability link nurse roles with additional training, and holds a weekly Pressure Ulcer panel to discuss incidents of pressure damage.
Rachel Garrett
All Responded
2023-0218
27 Jun 2023
West Sussex
Integrated Health Board NHS Sussex
NHS England
Concerns summary (AI summary)
A technical issue regarding the employment status of Mental Health Liaison staff prevents them from detaining patients under the Mental Health Act in acute hospitals, creating a serious risk of vulnerable patients absconding.
Action Planned
(AI summary)
NHS England notes that pathway reviews are being undertaken, SPFT is in the planning stages of putting together a business case for direct employment of Mental Health Staff by the acute providers and Sussex ICB are investigating the issues raised in the Report with SPFT and considering any improvements that can be made to the safety of patients. NHS England will also raise the case with the Department for Health and Social Education. NHS Sussex will make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care Hospitals and also to look at workforce and practices with their Providers to try to resolve these issues on a local level.
Stephen Richardson
All Responded
2023-0209
22 Jun 2023
Liverpool and Wirral
Department of Health and Social Care
NHS England & NHS Improvement
Concerns summary (AI summary)
There is an ongoing national shortage of acute psychiatric beds, preventing patients with severe mental disorders from accessing immediate inpatient assessment and treatment, which has not improved since 2019.
Action Taken
(AI summary)
NHS England states there is constant pressure on acute psychiatry bed availability. They have taken actions linked to bed management, and all reports received are discussed by the Regulation 28 Working Group. From a CM ICB perspective wider bed management/availability issues are being continually addressed. The Department of Health and Social Care notes NHS England and Cheshire and Merseyside Integrated Care Board have provided a response. Nationally, spending on mental health services has increased by £4.7 billion, including introducing new models of care in the community.
David Wood
All Responded
2023-0181
7 Jun 2023
Milton Keynes
John Radcliffe Hospital and MK together…
Concerns summary (AI summary)
There was a failure to communicate delirium symptoms to the GP and educate the family on post-surgical discharge care, highlighting a need to review discharge protocols following heart surgery.
Action Taken
(AI summary)
The POA clerking proforma was amended to include previous mental health and substance use. A discharge coordinator was appointed, and the nursing team educated on support services. Consent-form stickers were updated to include delirium as a possible complication, and the process for psychological medicine referrals was clarified.
Carl Thompson
All Responded
2023-0157
16 May 2023
Manchester South
Pennine Care NHS Foundation Trust
Concerns summary (AI summary)
Inadequate risk assessments for patient leave, combined with a failure to follow up on family concerns about substance misuse, led to missed opportunities for intervention. The patient was not seen face-to-face as policy required and lacked a dedicated care coordinator, while the Trust's action plan remains uncompleted.
Action Taken
(AI summary)
The trust has revisited its investigation report to support review of action plans, re-established a Just Culture meeting, is considering updated training for investigation authors, established a PSIRF implementation group, made patient safety training available online, and planned to share learning slides around inquest preparation.
Drew Howe
All Responded
2023-0155
15 May 2023
Manchester South
Pennine Care NHS Foundation Trust
Concerns summary (AI summary)
The Trust's investigation into the death was critically deficient, failing to fully analyze events, consider the patient's perspective, or derive comprehensive learning.
Action Planned
(AI summary)
The Trust will address the coroner's concerns by several actions including; offering awareness sessions, trust wide learning, case reflection with teams and ensuring assessment information is shared between services. They will also explore training around understanding trauma.
Bency Joseph
All Responded
2023-0148
7 May 2023
Essex
Essex Partnership NHS Foundation Trust
Concerns summary (AI summary)
There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also deficient, excluding key stakeholders.
Action Taken
(AI summary)
The Trust has completed a Clinical Review into the death, shared learning with the Chair of the Clinical Review Group, and responded to the family's concerns raised after the inquest. They have also appointed a Family Liaison Officer.
Joshua Asprey
All Responded
2023-0147
5 May 2023
East Sussex
National Institute for Health and Care …
Royal Pharmaceutical Society
Concerns summary (AI summary)
Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this potential risk with patients.
Noted
(AI summary)
NICE acknowledges the report but states that responsibility for the BNF content lies with BMJ Group and the Royal Pharmaceutical Society, so they cannot comment on the concerns raised. BNF Publications will use communications, including a newsletter and social media, to remind users how to find drug class information within content, including monographs and treatment summaries.
Evelina Vilkiene
All Responded
2023-0082Deceased
6 Mar 2023
East London
North East London Foundation Trust
Concerns summary (AI summary)
The mental health team failed to conduct detailed risk assessments or implement risk management plans during care transitions and medication weaning for a patient at increased self-harm risk, and did not ensure required weekly reviews.
Action Planned
(AI summary)
The Trust has agreed to take actions to address concerns raised, detailed within an attached action plan.