Other related deaths

PFD Category
Reports: 776 Areas: 72 Earliest: Aug 2013 Latest: 6 Mar 2026

75% response rate (above 62% average). 46% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).

Response Status
Responded 580 No Response 5 Historic 163 Pending 12
AI Classification
Action Taken 46%
Action Planned 31%
Noted 16%
Disputed 7%
Based on 318 classified responses
Reports by Quarter
PFD Reports
776 results
Stephen Cloudsdale
Partially Responded
2022-0035 3 Feb 2022 Cumbria
Cumbria County Council National Highways
Concerns summary Highway safety concerns on the A66 include inadequate lighting and warning signage for crossing vehicles, high traffic speeds, and an insufficient central reservation width.
Mark Jones
All Responded
2022-0040 3 Feb 2022 Manchester South
Department of Health and Social Care
Concerns summary Significant backlogs are delaying patient appointments, and the absence of a national protocol for dentists to include photographs with referrals hinders triage accuracy, risking urgent cases being missed.
Jake Cahill
All Responded
2022-0032 1 Feb 2022 Cornwall & the Isles of Scilly
Youth Justice Board for England and Wal…
Concerns summary Vulnerable young people complete self-assessment forms without professional discussion about sensitive issues, a gap compounded by inadequate guidance from the Youth Justice Board.
Oskar Nash
All Responded
2022-0031 31 Jan 2022 Surrey
Surrey and Borders Partnership NHS Foun… Surrey County Council Department of Health and Social Care +3 more
Concerns summary Child mental health services lack mandatory Autism training for triage staff, risking inadequate understanding and inappropriate closure of referrals. Routine referrals are automatically deemed low risk, despite potential for significant harm.
Eirlys Roberts
All Responded
2022-0034 31 Jan 2022 North West Wales
Minister for Health and Social Services…
Concerns summary A critical shortage of residential and nursing placements in Gwynedd prevents elderly patients from accessing appropriate care as their needs evolve, posing a risk to their well-being.
Finnian Kitson
All Responded
2022-0023 27 Jan 2022 Manchester City
Universities and Colleges Admissions Se…
Concerns summary Application forms fail to explicitly separate mental health from "disability" or "special needs," deterring disclosure and preventing essential support for students with mental health conditions.
Ketheeswaren Kunarathnam
All Responded
2022-0030 26 Jan 2022 West London
Home Office
Concerns summary Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Anthony Rode
All Responded
2022-0021 25 Jan 2022 Norfolk
Great Yarmouth Borough Council and Cais…
Concerns summary A dispute over land responsibility left a coastal area unmaintained, obscuring Coastwatch views and leading a volunteer to undertake dangerous grass strimming, hindering life-saving operations.
Anthony Walgate, Gabriel Kovari, Daniel Whitworth and Jack Taylor
Partially Responded
2022-0017 21 Jan 2022 East London
Department for Culture, Media and Sport College of Policing Metropolitan Police Service +1 more
Concerns summary Police investigations were marred by a significant number of "very serious and very basic investigative failings," including a profound lack of curiosity and errors, with terrible consequences.
Terance Radford
All Responded
2022-0014 18 Jan 2022 Nottingham City and Nottinghamshire
Minister of State for Prisons and Proba…
Concerns summary The Home Detention Curfew policy allows early release of high-risk prisoners without adequate assessment of their harm to others or multi-agency information sharing for risk management.
Jan Goodliffe
Historic (No Identified Response)
2022-0009 14 Jan 2022 Essex
NHS England and Essex Partnership Unive…
Concerns summary Unqualified social workers conducted home mental health assessments, missing critical opportunities to seek medical expertise regarding medication interactions, which may have contributed to the deceased's death.
James Emmerson
Historic (No Identified Response)
2022-0002 5 Jan 2022 Bedfordshire and Luton
East London NHS Foundation Trust Association of Directors of Adult Socia… Royal College of Psychiatrists +2 more
Concerns summary Ambiguous Mental Health Act guidance resulted in a flawed practice where individuals detained under Section 136 were discharged without assessment by an Approved Mental Health Professional, increasing risk of self-harm or suicide.
Richard Sanders
All Responded
2022-0003 5 Jan 2022 Gloucestershire
British Diving Safety Group University Hospitals Sussex NHS Foundat… National Diving and Activity Centre
Concerns summary There is insufficient awareness of immersion pulmonary oedema risks in diving, a lack of mandatory "fitness to dive" medical certificates, and inefficient diver removal procedures at diving centres.
Yousef Makki
All Responded
2021-0434 31 Dec 2021 Greater Manchester South
Department for Education
Concerns summary A concerning culture among teenagers normalises knife possession, with easy access to weapons and a lack of understanding of the inherent risks.
Mark Castley
All Responded
2021-0427 22 Dec 2021 London Inner South
HM Prison and Probation Service
Concerns summary The risk of impulsive self-harm was not fully assessed, particularly concerning future contexts like post-sentencing, possibly due to unclear interpretation of risk assessment policies.
Oliver Weston
Historic (No Identified Response)
2021-0422 20 Dec 2021 Lancashire & Blackburn with Darwen
OFSTED
Concerns summary An OFSTED inspection of a children's home was deficient, failing to consider relevant safeguarding information and misinterpreting evidence. Lack of guidance for publishing reports in "exceptional circumstances" led to arbitrary decisions.
Nichola Lomax
Partially Responded
2021-0433 17 Dec 2021 Manchester North
Northern Care Alliance NHS Foundation T… NHS England Royal College of Psychiatrists +7 more
Concerns summary Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.
James McKeough
All Responded
2021-0414 9 Dec 2021 West Sussex
Department for Transport
Concerns summary The positioning, brightness, and color of rear flashing LED lights on trailers can mask or be misinterpreted as turn indicators, hindering other drivers' ability to discern turning intentions.
Terence Talbot
All Responded
2021-0419 3 Dec 2021 Mid Kent and Medway
Department for Work and Pensions Maidstone & Tunbridge Wells NHS Foundat… Kent & Medway Social Care Partnership T…
Concerns summary Inadequate clinical assessments, including mental capacity and specialist dermatology review, combined with insufficient nutritional care, and a rigid DWP policy requiring a critically ill inpatient to attend in person for benefits.
Khadija Ahmed
All Responded
2021-0410 2 Dec 2021 Inner North London
Swiss Cottage Special School
Concerns summary School staff, including the teaching assistant, lacked cardiopulmonary resuscitation (CPR) training, resulting in no CPR being attempted during a child's cardiac arrest.
James Lacey
Historic (No Identified Response)
2022-0073 29 Nov 2021 Lancashire & Blackburn with Darwen
Home Office
Concerns summary Harmful substances are easily purchased with less rigorous control than 'regulated poisons,' lacking restrictions like licensing and record-keeping, posing a risk of misuse.
Jordan Mhlanga-Veira
All Responded
2021-0403 26 Nov 2021 Berkshire
Environment Agency and National Trust
Concerns summary Urgent review needed for safety measures at non-tidal waters, including warning signs, throw ropes, and buoys, with consideration for applying similar approaches to those used for tidal waters.
Frances Thomas
All Responded
2021-0408 26 Nov 2021 Surrey
Department for Education
Concerns summary Outdated e-security guidance from the Department of Education led to inadequate web filtering, lack of oversight for blocklists, and insufficient scrutiny of age-inappropriate online content in schools.
Neil Stewart
Historic (No Identified Response)
2021-0400 25 Nov 2021 Newcastle upon Tyne
Bounce Til I Die
Concerns summary There was an absence of clear, written safety policies and protocols for venues and event providers, leading to inadequate communication of risks and poorly defined responsibilities for guests.
Marshall Metcalfe and Jane Ireland
Historic (No Identified Response)
2021-0406 25 Nov 2021 Blackpool & Fylde
Department of Health & Social Care
Concerns summary Children's Social Care disengages during mental health admissions, leading to a lack of social worker input in discharge planning and continuity of care, which increases patient risk upon leaving the facility.