Other related deaths

PFD Category
Reports: 783 Areas: 72 Earliest: Aug 2013 Latest: 14 Apr 2026

76% response rate (above 63% average). 34% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).

Response Status
Responded 592 No Response 10 Historic 174 Pending 3
AI Classification
Action Taken 34%
Action Planned 40%
Noted 24%
Disputed 1%
Based on 1,081 classified responses
Reports by Quarter
PFD Reports
783 results
Catherine Oliver
Response Pending
2026-0215 14 Apr 2026 Oxfordshire
Sanctuary Housing Association
Concerns summary (AI summary) Prolonged storage of household items in the main living area created a hazard for an elderly tenant, and there were no clear policies or time limits governing such storage or mitigating steps.
Susan Toft
Response Pending
2026-0214 14 Apr 2026 Manchester South
British Health Trades Association Wheelchair Alliance Wheelchair Accessible Vehicle Converter…
Concerns summary (AI summary) The detachment of a wheelchair seat cushion after only 9 months raised concerns about the robustness of the attachment method, and a lack of assessment of the vehicle restraint system's fit contributed to the deceased being thrown into the footwell during transport.
Joshua Perry
Response Pending
2026-0206 7 Apr 2026 Liverpool & Wirral
Secretary of State for building safety,…
Concerns summary (AI summary) A conflict exists between Building Regulations and BSI Standards regarding the measurement of barrier heights when a wall or parapet is used as guarding, and the guidance does not mention horizontal railings being a climbing risk for adults and children over 5 years old.
Jack Saunders
No Identified Response
2026-0187 31 Mar 2026 Lancashire with Blackburn and Darwen
Scouting Association
Concerns summary (AI summary) Borrowed equipment lacked instructions, and while national carbon monoxide poisoning risk training existed, it had not reached trainers within individual troops; the deceased had also observed leaders using gas equipment in tents previously.
Edith Millington
All Responded
2026-0183 27 Mar 2026 Manchester South
Sai SKN Ltd
Concerns summary (AI summary) The structure/design of the store's access ramp is unsafe, because it is not fixed to the ground, the rubber mat is not fixed, there are no easily accessible handrails, and the ramp is too short, making the slope steeper.
Action Taken (AI summary) • The metal access ramp has been completely removed. • The entrance has been restructured to eliminate the previous ramp arrangement and replaced with a small, stable step. • Additional fixed grab rails have been installed on both sides of the entrance.
Richard Hopkins
Partially Responded
2026-0155 23 Mar 2026 Coventry and Warwickshire
Driver and Vehicle Standard Agency Health and Safety Executive Society of Motor Manufacturers and Trad…
Concerns summary (AI summary) An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance or sector awareness.
Action Planned (AI summary) • The Health and Safety Executive (HSE) acknowledged that the proximity risk associated with visual inspection of air suspension systems was previously unrecognised. • The HSE stated that employers are required to manage risks to their employees so far as is reasonably practicable. • DVSA engaged fully with the Health and Safety Executive (HSE) and attended hearings to determine whether there was anything we could or should do. • DVSA engaged with the vehicle manufacturer in the same way we would where there is the suggestion of a potential vehicle safety defect. • DVSA will continue to collaborate with HSE to find opportunities to discuss mitigations that employers can implement to address this kind of problem, for example, in any trade communications or guidance.
Peter Coates
All Responded
2026-0154 23 Mar 2026 Teesside and Hartlepool
NHS England
Concerns summary (AI summary) There is a critical gap in ambulance response categories, as some patients requiring an immediate response to prevent life-threatening deterioration do not meet Category 1 criteria.
Action Taken (AI summary) • NHS England implemented new ambulance standards across the country in 2017. • NHS Ambulance Services are required to process 999 calls through an approved triage system. • The systems are used to prioritise 999 calls received into Ambulance Services’ Emergency Operations Centres (EOCs).
Asher Blackman
All Responded
2026-0133 6 Mar 2026 North London
Central London Community Healthcare NHS…
Concerns summary (AI summary) District Nurses failed to record next of kin details and the 'no access' policy was inadequate, lacking provision for police involvement when a patient's life was at risk.
Action Taken (AI summary) • The Trust has undertaken a review of District Nursing referral forms, initial assessment documentation, and clinical system configurations. • Next of kin and emergency contact details are now mandatory fields and are completed at triage where the information is available. • The Trust has undertaken a programme of Trust‑wide engagement events to review clinical practice and the application of the ‘No Access: Not Seen: Disengagement Policy’.
Kay Wilson
All Responded
2026-0132 6 Mar 2026 County Durham and Darlington
Durham County Council
Concerns summary (AI summary) An unguarded breach in a stone wall provides unrestricted public access to a dangerous 9-meter vertical drop onto rocks and the river below.
Action Taken (AI summary) • Officers from the council’s health and safety team attended the location to inspect the breach in the stone wall. • A site-specific risk assessment for the site had been previously undertaken by council officers for this area and this followed national guidance and methodology; this previous assessment was reviewed and updated to reflect the findings from the inquest. • The council will install a steel fencing section to fully close the gap in the existing stone wall and prevent unrestricted public access to the drop below.
Caroline Adeyelu
No Identified Response
2026-0129 5 Mar 2026 East London
East London Foundation Trust Metroplolis North East London Foundation Trust
Concerns summary (AI summary) Mental health services demonstrated a poor appreciation of risks from an adult child's mental illness to a parent, due to insufficient safeguarding training and lack of multi-agency risk assessment. There were also significant communication breakdowns between mental health services and the police.
Susan Samson
No Identified Response
2026-0120 2 Mar 2026 County Durham and Darlington
Darlington Borough Council
Concerns summary (AI summary) Excessive delays by the council in fitting a requested second banister rail in a tenant's home exposed the individual to a prolonged, avoidable risk of falls and potential death.
William Webb
No Identified Response
2026-0117 26 Feb 2026 Cheshire
Canal & River Trust
Concerns summary (AI summary) A canal near student accommodation lacks safety equipment and warning signage, making it difficult for inebriated individuals to exit the water if they fall in.
Susan Samson
All Responded
2026-0112 23 Feb 2026 County Durham and Darlington
County Durham & Darlington NHS Foundati…
Concerns summary (AI summary) A patient was discharged home without consistently demonstrating safe stair use, and the current policy would allow this to recur, posing a future fall risk.
2 responses from Darlington Borough Council, County of Durham and Darlington NHS Foundation Trust
Sean Williams
All Responded
2026-0105 20 Feb 2026 Inner North London
Metropolitan Police Service Serco Prison Transport Services
Concerns summary (AI summary) A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide their location to emergency services.
Noted (AI summary) • Operational reminders have been issued reminding Custody Officers to ensure medical requests are made. • A new protocol for 'case finding' was implemented in November 2025, where the HCP on duty runs through the custody whiteboard with the Grip Sergeant and checks if there are any detainees who may have unmet medical needs.
Jacqueline Joseph
All Responded
2026-0102 19 Feb 2026 Bedfordshire and Luton
Luton Community Housing Ltd
Concerns summary (AI summary) The housing association property had two incorrectly installed battery-operated smoke alarms, posing a fire safety risk.
1 response from Squared
Samuel Dickinson
All Responded
2026-0082 10 Feb 2026 Manchester West
Department of Health and Social Care Home Office
Concerns summary (AI summary) Gaps in firearms legislation mean licence holders are not required to self-report medical conditions, and GPs are not obligated to record licences or report relevant issues to police.
Noted (AI summary) • A new Statutory Instrument will add a new condition to firearms and shotgun licences to require the holder to inform the police if they begin to suffer from a new relevant medical condition, or if an existing condition significantly worsens, during the lifetime of the licence. • A new licensing condition will require the licence holder to inform the police if they consult a third-party medical practitioner who is not their GP.
Helen Patching, Rachael Patching and Corey Longdon
No Identified Response
2026-0081 9 Feb 2026 South Wales Central
Bannau Brycheiniog National Park Natural Resources Wales Neath Port Talbot County Borough Council +2 more
Concerns summary (AI summary) Inadequate signage fails to address significant falling risks in 'Waterfall Country', and poor mobile phone signal hinders emergency services' response times.
Janet Springall
No Identified Response
2026-0074 7 Feb 2026 Blackpool & Fylde
Care Quality Commission Department of Health and Social Care
Concerns summary (AI summary) Hospital emergency departments face significant pressures, causing unwell patients to remain in ambulances and delaying critical treatment, which reduces survival chances.
Bonita Cleary
No Identified Response
2026-0067 7 Feb 2026 Blackpool & Fylde
Care Quality Commission Curo Care Delahey’s
Concerns summary (AI summary) A lack of awareness among care staff regarding when CPR should be attempted risks potentially reversible deaths in vulnerable residents.
Roger Leadbeater
All Responded
2026-0041 23 Jan 2026 South Yorkshire West
Greater Manchester Police South Yorkshire Police
Concerns summary (AI summary) Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.
Action Taken (AI summary) • A new, purpose-designed form has been created to record the transfer of responsibility for a missing person. • A mandatory task has been embedded within Compact, our MFH management system, providing officers with an automatic prompt at the relevant stage of the investigation and includes a direct link to the new form. • A comprehensive communication has been circulated across the organisation, outlining the new process, the rationale for its introduction and the tragic circumstances that brought the issue to light.
Clive Hyman
All Responded
2026-0034 22 Jan 2026 Inner North London
Association of the British Pharmaceutic… Medicines and Healthcare Products Regul… Medicines UK
Concerns summary (AI summary) Patient information leaflets for Apixaban do not adequately advise on actions following head trauma, risking delayed medical intervention for intracranial bleeds in patients taking anticoagulants.
Noted (AI summary) The ABPI, as a trade association without regulatory authority, has made the originator company, Bristol Myers Squibb (BMS), aware of the coroner's report and concerns regarding apixaban patient safety information and labelling. MedicinesUK states its member companies will comply with any future changes to product information regarding anticoagulants and head trauma warnings, should such changes be required by the MHRA. The MHRA has completed a preliminary assessment and initiated a full review across all Direct Oral Anticoagulants (DOACs) and warfarin regarding patient information leaflet warnings for head trauma, with plans to seek expert advice on potential updates.
Drew Greaves-Pimblett
All Responded
2026-0008 8 Jan 2026 Sefton, St Helens and Knowsley
NHS England
Concerns summary (AI summary) National telephone triage pathways lack adequate guidance for call handlers on probing questions for critical symptoms like breathing and body temperature, hindering accurate assessment for CPR.
Noted (AI summary) NHS England acknowledges the concerns and notes that the North West Ambulance Service followed protocol, but also outlines national work taking place around Reports to Prevent Future Deaths, ensuring learnings are shared across the NHS.
Mohammed Choudhury
All Responded
2026-0005 6 Jan 2026 Bedfordshire and Luton
East London NHS Foundation Trust
Concerns summary (AI summary) Inadequate management of a patient's paranoid schizophrenia included failure to address non-concordance with anti-psychotic medication and withdrawal of medication support without GP checks, despite known risks.
Action Taken (AI summary) The Trust has reviewed and reinforced its policy on medication non-concordance, embedded an audit cycle to ensure compliance, and trained staff to access and use the NHS Summary Care Record to verify prescription issues.
John Oates
All Responded
2025-0646 18 Dec 2025 Cumbria
Electricity Networks Association
Concerns summary (AI summary) Manufacturing defects in widespread porcelain tension disc insulators cause failures that can lead to dangerous low-hanging power lines, a risk compounded by insufficient adoption of detection technology.
Action Planned (AI summary) The ENA has convened member companies to improve arrangements following the death. They plan to produce industry guidance on health and safety risk assessments for low-hanging overhead lines and promote innovative monitoring technologies by September 2026.
Anthony Lodge
All Responded
2025-0669 15 Dec 2025 County Durham and Darlington
Internation Scientific Supplies Ltd
Concerns summary (AI summary) Urine sample bottles lacked expiry dates, resulting in the use of out-of-date containers and subsequent delays in laboratory processing, posing a risk of future harm.
Noted (AI summary) International Scientific Supplies Ltd states its urine specimen containers are manufactured and labelled according to UK regulatory requirements, including expiry dates on outer packaging, and that the product complied with obligations at the time of supply. They assert controls were in place and labeling was compliant.