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
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.
Daniel Lyle
Historic (No Identified Response)
2023-0170 23 May 2023 Inner West London
College of Policing Metropolitan Police Service
Concerns summary (AI summary) A police officer responding to a mental health crisis reported insufficient specific training on symptoms, presentation, and de-escalation techniques for individuals experiencing psychotic episodes. The officer's training was described as a "patchwork" over many years.
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.
Ben Shipley
Historic (No Identified Response)
2023-0140 27 Apr 2023 West Yorkshire Western
NHS England NHS Improvement
Concerns summary (AI summary) A systemic delay in securing mental health beds means patients assessed for Section 2 are often left in A&E for hours, unable to be legally detained and without appropriate specialist care.
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.
Eric Huber
Historic (No Identified Response)
2023-0424 31 Jan 2023 Exeter and Greater Devon
Devon County Council
Concerns summary (AI summary) Missed opportunities to fully assess the deceased's risk and needs, coupled with a failure to conduct multi-agency and multi-disciplinary discussions, compromised his care.
Samantha Boazman
All Responded
2023-0034Deceased 31 Jan 2023 Leicester City and South Leicestershire
Inmind Healthcare Group
Concerns summary (AI summary) The report raises concerns that emergency response protocols at the hospital involved staff assessing a situation and then collecting equipment, rather than bringing it immediately, and observations were recorded in a predictable manner, not therapeutically.
Action Taken (AI summary) Following the death, an emergency bag is now in every ward in all Inmind hospitals. Regular training and competency assessments are now undertaken regarding observations, and a new radio protocol has been implemented for staff to communicate effectively in emergencies.
Andrew Shirley
All Responded
2023-0063Deceased 27 Jan 2023 Worcestershire
Various
Concerns summary (AI summary) HMP Hewell healthcare and mental healthcare staff failed to identify, record, and mitigate the deceased's suicide risk, and did not adequately share information with prison staff. The Duty Governor also failed to make sufficient enquiries regarding health screens.
Action Planned (AI summary) Following Mr Shirley’s death, a thorough investigation into the care delivered by the Midlands Partnership Foundation Trust was undertaken. The Access Team call handler aide memoire has been updated. Practice Plus Group have healthcare staff being trained to deliver ACCT training. Training compliance at HMP Hewell is currently 88%, and further dates have been arranged to ensure full compliance by 31 March 2023. Training has also been delivered to all healthcare staff regarding the initial segregation health screen. HMP Hewell is delivering training sessions that incorporate both ACCT v6 and SASH training to all staff with the expectation that this will be completed by July 2023. HMP Hewell has developed Duty Governor guidance for managing the risk of segregation and delivered a training session to all Duty Governors in March 2023.
Andrew Largin
All Responded
2023-0027Deceased 25 Jan 2023 Inner North London
East London Foundation Trust
Concerns summary (AI summary) The report identifies a failure to allocate a team member promptly after discharge from the crisis team, a lack of reassessment despite concerning information, and poor communication between teams regarding patient pathways.
Action Taken (AI summary) The Trust has reviewed procedures, met with managers, and is implementing a training programme for Neighbourhood Teams to highlight clinical risk when triaging incoming referrals, which started in March 2023 and runs monthly for 6 months. WWNT members will be required to attend the next Coroner’s Training provided by the Trust’s Legal Affairs Team.
Sophia Ayuk
Partially Responded
2023-0022Deceased 20 Jan 2023 East London
Department of Health and Social Care East London Foundation Trust
Concerns summary (AI summary) The patient was not assessed for venous thromboembolism (VTE) risk as per trust policy, and instructions for monitoring food and fluid intake were inadequately followed during her inpatient care.
Action Taken (AI summary) The Trust has reviewed its VTE policy, disseminated a VTE screening alert, updated new doctors' induction materials, added anti-psychotics to the VTE assessment tool, and included food and fluid chart sessions in physical health training. They have implemented a new nutrition policy, hired specialist dieticians, introduced training on nutrition screening, launched a nutrition and dietetics page, and introduced a dietician referral system. NCfMH has also introduced daily and weekly food/fluid chart checks and a new template for decision making.
Donna Neill
Historic (No Identified Response)
2022-0299 28 Sep 2022 East London
East London Foundation Trust
Concerns summary (AI summary) The report identifies a failure to document, assess, or manage the risk of a patient taking medication prescribed to her husband, and the Trust's internal investigation did not identify this failing.
Shona Campbell
Response Pending
2022-0202 Manchester City
Alternative Futures Group Greater Manchester Mental Health NHS Fo… Safety Matters (Legal) Limited +1 more
Concerns summary (AI 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.
Paul Meadows
All Responded
2022-0201 Suffolk
Department of Health and Social Care Ipswich and East Suffolk Clinical Commi…
Concerns summary (AI 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 (AI summary) The Integrated Care System (ICS) repurposed the First Response Service to NHS111 option 2 in April 2022, which has reduced calls and improved response times. The ICS has also provided additional funding to increase capacity through voluntary sector partners and will continue working to reduce staff vacancies. The Department notes that the CQC is actively addressing patient safety issues at Norfolk and Suffolk NHS Foundation Trust through a Section 29A Warning Notice and follow-up inspections, while NHS England supports the Trust via a Recovery Support Programme. Nationally, the department invested £111 million in 2021/22 and is implementing plans to expand the mental health workforce by over 27,000 by 2023/24.
Michael Vince
All Responded
2022-0198 East London
North East London Foundation Trust and …
Concerns summary (AI 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 (AI summary) North East London NHS Foundation Trust acknowledges concerns regarding Zopiclone prescription and monitoring. They have undertaken a learning review, developed an action plan, and updated their practice regarding medication monitoring and compliance, with ongoing monitoring planned. High Street Surgery has completed a clinical audit of Zopiclone prescriptions over the past two years, conducted structured medication reviews for most long-term patients, and commenced more proactive referrals to specialist mental health services. They also participated in a meeting where NELFT committed to a wider audit and developing a safe-prescribing training package.
Zsolt Kirjak
Response Pending
2022-0197 Inner West London
Portland Practice, Central and North We…
Concerns summary (AI 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.
Alun Davies
All Responded
2022-0196 Hampshire, Portsmouth and Southampton
South Western Railway and BTP Fatal Inv…
Concerns summary (AI 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 (AI summary) South Western Railway has already fitted trespass gates, witches hats, and anti-tread guards to deter unauthorised track access at Portchester Station in 2020-2021. They are also discussing with Network Rail to review the station's status regarding suicide risks, but found no requirement to increase staffing or introduce 24/7 CCTV surveillance.
Khalid Yousef
All Responded
2022-0193 Birmingham and Solihull
NHS England, Birmingham and Solihull Me…
Concerns summary (AI 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.
Noted (AI summary) NHS England clarifies that while the Liaison & Diversion service model does not directly commission psychiatrists, access can be arranged via urgent referral. They state that a Career and Competency Framework for L&D services, published in 2018, is currently under review, and regional commissioners will consider it for workforce and quality issues. NHS England clarifies that Liaison and Diversion services do not directly commission psychiatrists but are for referral. They are developing a new service specification to clarify expectations for access to psychiatry and are reviewing the L&D career and competency framework. West Midlands Police will create a formal escalation process for custody staff disputing Liaison and Diversion decisions, review mental health training for custody officers, and provide clear advice to frontline staff on the L&D function. These actions are planned within six months. West Midlands Police will create a formal escalation process for custody staff regarding Liaison & Diversion decisions, review mental health training for custody officers/staff, and provide clear advice on the L&D function within six months. Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and introduce reflective practice groups with psychologists by October 2022. Birmingham and Solihull Mental Health Trust plans to discuss liaison clarity with West Midlands Police, develop internal communications about the L&D team's role, and review/update the L&D induction programme and introduce reflective practice groups with psychologists by October 2022. NHS England clarifies that the Police Custody Healthcare Service (PCHS) policy and commissioning responsibilities lie with the Home Office and Police and Crime Commissioners (PCCs) respectively, not NHS England. They state their role is advisory, and they will continue to work collaboratively with the National Police Chiefs Council (NPCC) to align PCHS and Liaison & Diversion service specifications. The Home Office clarifies that commissioning for L&D services is for NHS England and police custody healthcare services for PCCs, and it is not their place to intervene. However, Home Office officials are working with the NPCC, NHS England, and DHSC to improve escalation processes and mental health management in custody, with a view to the NPCC issuing new guidance.
Keith Nottle
All Responded
2022-0189 Nottingham City and Nottinghamshire
Nottinghamshire Healthcare Trust and Tu…
Concerns summary (AI 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 Planned (AI summary) Turning Point has reviewed and refreshed helpline worker roles, agreed a Standard Operating Procedure (SOP) with Nottinghamshire Healthcare Trust, ensured staff familiarity with the SOP, introduced additional monitoring and audits, and agreed a competency framework. Nottinghamshire Healthcare is undertaking a comprehensive review of its Crisis Resolution and Home Treatment service, which is currently underway and will lead to an improvement plan by 30 November 2022.
Volodymyr Korol
Response Pending
2022-0170 Surrey
Iden Manor Nursing Home Whitepost healthcare Group
Concerns summary (AI summary) The care provider failed to investigate causative failures in mental capacity assessments, information sharing, and vital sign escalation. Similar deficient practices may pose a risk at their other operational nursing home.
Mena Terefi
Historic (No Identified Response)
2022-0166 West London
NHS England West London Mental Health NHS Trust
Concerns summary (AI summary) Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Andrew Nixon
All Responded
2022-0165 Dorset
Somerset NHS Foundation Trust
Concerns summary (AI 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 Planned (AI summary) Somerset NHS Foundation Trust is undertaking a Quality Improvement project to simplify carer referral processes, with learning to inform revisions to their Carer’s Assessment service procedure in 2023. They plan to issue staff briefings on consent and confidentiality, explore changes to their electronic recording system, update clinical risk training, and ensure co-produced safety plans are shared upon patient discharge.