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).

PFD Reports
783 results
Henry Boddy
Partially Responded
2021-0227 2 Jul 2021 Inner London North
Fire and Communities, Ministry of Housi… Home Office
Concerns summary (AI summary) There is a gap in enforcement powers regarding fire risks in residential properties, specifically the risks of a fire load arising from hoarding behaviour.
Noted (AI summary) The Home Office acknowledges concerns about fire risks from hoarding but suggests a multi-agency approach is more appropriate than enforcement under the Fire Safety Order. They highlight the role of Safe and Well visits and safeguarding referrals.
Samantha Singh
Historic (No Identified Response)
2021-0225 2 Jul 2021 East London
Hainault Surgery SMA Medical Practice
Concerns summary (AI summary) A patient's RAST test results were wrongly categorised as normal, leading to delayed action. Subsequently, only one EpiPen was prescribed against NICE guidance, and no allergy clinic referral or follow-up was offered.
Joan Prescott
Historic (No Identified Response)
2021-0223 30 Jun 2021 Plymouth Torbay and South Devon
Devon County Council
Concerns summary (AI summary) Safeguarding considerations, particularly regarding a known poor property condition, were not adequately recorded or prioritised during a welfare visit. This represented a missed opportunity to formally address broader safeguarding concerns.
Katie Locke
Historic (No Identified Response)
2021-0222 29 Jun 2021 Hertfordshire
Hertfordshire Constabulary Hertfordshire Partnership University NH… National Probation Service
Concerns summary (AI summary) Knowledge and understanding of the Potentially Dangerous Persons (PDP) process were sporadic among police and partner agencies. This lack of dissemination and training hinders the multi-agency process from effectively protecting the public.
Netlyn Robinson
All Responded
2021-0219 23 Jun 2021 West Yorkshire Eastern
Leeds City Council
Concerns summary (AI summary) Upon the deceased's return home, there was no falls pendant or alarm, the telephone line was not connected, there was no risk assessment, and the heating was not working; the social worker had not been shown a checklist for issues to check prior to a vulnerable person returning home and there were no processes in place to outline what social services would or would not do to ensure the premises were suitable.
Action Taken (AI summary) Leeds City Council confirms immediate action has been taken on a number of issues raised and a clear plan is in place to address those for which there is a longer timescale, as outlined in the attached action plan which refers to providing suitable equipment and suitable care packages.
Zainab Hashim and Tafaoul Abdulkarim
All Responded
2021-0205 16 Jun 2021 Stoke-on-Trent & North Staffordshire
Stoke-on-Trent City Council
Concerns summary (AI summary) Residents in council-owned blocks of flats were unaware of the "Stay Put" fire policy, and communication methods have not changed despite this proven lack of awareness, risking future deaths.
Action Planned (AI summary) The Council already provides fire safety information in multiple languages and displays notices; they plan to increase targeted digital communication and explore displaying notices about requesting translated information and are piloting the provision of portable induction loops to assist tenants with hearing impairments.
Ian Hall
Partially Responded
2021-0202 14 Jun 2021 Greater Manchester South
Medicines and Healthcare Products Regul… NHS Stockport Clinical Commissioning Gr…
Concerns summary (AI summary) Incorrect medication was dispensed, and pharmacies lack checks to prevent vulnerable adults, whose non-clinical carers administer medications, from receiving wrong prescriptions.
Action Planned (AI summary) The MHRA will review the packaging of the amitriptyline and atenolol medicines and if improvements could be made they will contact the pharmaceutical manufacturers who supply these medicines and seek changes.
Clive Rivers
All Responded
2021-0199 10 Jun 2021 Manchester South
Department of Health and Social Care NHS England
Concerns summary (AI summary) Hospital policy prevented inpatient COVID-19 vaccination, and discharge delays led to infection. The discharge assessment failed to consider the patient's rapid COVID-19 decline vulnerability, resulting in an unsafe return to isolated accommodation.
Noted (AI summary) NHS England explains that vaccinations were initially prioritized for staff, discusses discharge policies aligned with national guidance, and highlights the use of Criteria to Reside for discharge decisions, with efforts to expedite discharges where possible. The Department of Health and Social Care extends condolences and explains the JCVI's role in vaccine prioritisation, highlighting the initial focus on reducing mortality and protecting healthcare staff. It also mentions support for hospital discharge pathways and ongoing reviews of COVID-19 deaths.
Emiel Malinski
All Responded
2021-0198 10 Jun 2021 Manchester South
Home Office
Concerns summary (AI summary) Miniature rifle ranges operate with minimal regulation, lacking essential safety measures such as secure weapon tethering, competent supervision, ammunition control, and first aid provisions.
Action Planned (AI summary) The Home Office is reviewing the firearms licensing exemption for miniature rifle ranges, prompted by the incident. They conducted a public consultation on tightening controls and will consider the responses before deciding on further measures.
Nicholas O’Brien
All Responded
2021-0197 9 Jun 2021 Hampshire, Portsmouth and Southhampton
British Kite Surfing Association
Concerns summary (AI summary) A kite-surfing radio device adhered to a helmet failed to detach when entangled, preventing depowering and leading to a fatal dragging incident. The device's attachment method was insecure, posing risks for similar helmet-mounted accessories.
Action Taken (AI summary) The British Kitesports Association issued recommendations to schools using BB-Talkin headsets or similar devices, including following manufacturer's instructions, checking equipment, making students aware of potential entanglement, and including guidelines in their Safety Management Systems.
Darrell Spear
Historic (No Identified Response)
2021-0196 8 Jun 2021 Greater Manchester South
Stockport Metropolitan Borough Council
Concerns summary (AI summary) Agencies failed to effectively manage identified self-neglect and hoarding risks, particularly fire hazards, due to poor inter-agency communication and a lack of clear strategy.
Angela Best
All Responded
2021-0194 4 Jun 2021 Inner North London
Ministry of Justice
Concerns summary (AI summary) A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Action Taken (AI summary) The MoJ is drafting discharge guidance for the Mental Health Casework Section (MHCS), identifying patients discharged prior to 2003 for MAPPA consideration, and revising court orders for new patients to highlight MAPPA responsibilities. They are also reviewing warrants issued in prison transfers to incorporate similar changes.
Pathushan Sutharsan
All Responded
2021-0193 4 Jun 2021 West Sussex
West Sussex County Council
Concerns summary (AI summary) A road junction on the Downs Link remains hazardous for cyclists, pedestrians, and equestrians, lacking safe crossing infrastructure, such as a Pegasus crossing or bridge, and suffering from poor sight lines.
Action Taken (AI summary) West Sussex County Council formed a chicane, installed warning signs, and cleared vegetation at the collision site. They have also adjusted speed terminal sign heights for equestrians and plan to add red surfacing and additional hedge cutting this summer.
Samantha Gould and Christine Gould
All Responded
2021-0184 Cambridgeshire and Peterborough
Cambridgeshire and Peterborough Foundat… Cambridgeshire County Council (CCC) The National Police Chiefs' Council
Concerns summary (AI summary) Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Action Planned (AI summary) The NPCC has implemented an immediate addition to the Authorised Professional Practice (APP) guidance for all UK Police Forces, focusing on police engagement with reluctant victims/witnesses and ongoing support strategies. The NPCC Lead is also communicating this change to Local Safeguarding Children Partnerships. The Trust is reviewing its AWOL policy (completion by Oct 2021), undertaking a full policy review over six months, reminding doctors of ICD 11 changes, and developing a new joint protocol for overnight assistance for high-need adolescent mental health patients. Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the YOUnited partnership (July 2021) to enhance emotional health and wellbeing services for children and young people, focusing on clear referral pathways and multi-agency support.
Samantha Gould
All Responded
2021-0186 28 May 2021 Cambridgeshire and Peterborough
Company Chemists’ Association General Pharmaceutical Council NHS England +1 more
Concerns summary (AI summary) There is a national gap in guidance for sharing mental health patient care plans and risk information with pharmacies, enabling vulnerable 16-17 year olds to access overdose medication.
Noted (AI summary) NHS E/I acknowledge a systemic weakness existed and is working with NHS Digital to allow information about local prescription plans to be added to Summary Care Records. They highlight existing NICE and GMC guidance on sharing information and safe medicine use. The RPS welcomes guidance/standards to ensure the NHS and other providers of care inform community pharmacies of patient safety plans. They highlight their existing guidance and campaigns on patient health records and safe transfers of care. The GPhC outlines its role in setting standards for pharmacies and pharmacists, noting that NHS England is better placed to provide information on national medication safety plans. They will share learnings from the case with stakeholders and encourage pharmacies to work more effectively with healthcare teams. The CCA will discuss the case at the next Community Pharmacy Patient Safety Group meeting to identify learnings and share best practice. They will also work with other organizations (GPhC, RPS, and NHS England) to consider how practice can be improved.
Anastasia Uglow
All Responded
2021-0216 24 May 2021 Avon
Department for Education
Concerns summary (AI summary) There is a critical need to raise sepsis awareness across all schools, as healthy teenagers can rapidly deteriorate, leading to tragic consequences if the condition is left untreated.
Action Planned (AI summary) The Department for Education noted the recommendations and is making progress by working with the Outdoor Education Advisers' Panel (OEAP) and the UK Sepsis Trust to update national guidance in relation to sepsis awareness, and intends to update its Health and safety responsibilities and duties for schools to reference the work of the OEAP.
Wilfred Breakell
All Responded
2021-0165 20 May 2021 County of Dorset
BCP Council
Concerns summary (AI summary) A lack of safety barriers between the highway and a storm drain at a road exit poses a significant risk of cyclists and vehicles falling into it.
Disputed (AI summary) BCP Council investigated the incident and concluded that it is not appropriate to introduce additional fencing to the inside of the bend on the slip road, but will continue to monitor the site in conjunction with the police.
Liam Kenyon
Historic (No Identified Response)
2021-0161 19 May 2021 Manchester North
Adullam Homes Housing Association
Concerns summary (AI summary) Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug checks or risk assessment updates. Welfare checks were inadequate due to staff shortages and poor escalation.
Todd Salter
All Responded
2021-0281 18 May 2021 South Yorkshire East
National Probation Service
Concerns summary (AI summary) A probation officer's inadequate knowledge of mental health services and poor inter-agency collaboration forced the deceased to seek treatment by committing criminal acts.
Action Taken (AI summary) The identified lack of knowledge and training gaps have been and continue to be dealt with at an individual level, briefing sessions on suicide prevention and processes have been updated in EQUIP. The Probation Service developed a new Target Operating Model (published in February 2021) which includes the implementation of the commitments set out in the Health & Social Care Strategy.
Paul Reynolds
All Responded
2021-0151 Suffolk
Brittania Jinky Jersey Limited Brittania Hotels Group Limited
Concerns summary (AI summary) Pontins' physical intervention policy was inadequate, lacking proper staff training, allowing unbadged personnel in restraints, and failing to ensure proper monitoring for positional asphyxia.
Action Planned (AI summary) The company is planning to remove ground restraint references from its Physical Intervention Policy and re-emphasise that non-badged staff are not permitted to participate in restraint. It is also investigating engaging external providers for annual refresher security training. Suffolk Constabulary has enhanced its training delivery and supporting guidance on officer assessments and use of force, and invested in a new skills management system to track training records. It is also reviewing training schedules and designing new scenarios for scene management.
Steven Oscroft
All Responded
2021-0162 12 May 2021 Nottingham City and Nottinghamshire
Driver and Vehicle Licensing Agency Paul Wainwright Construction Services L…
Concerns summary (AI summary) Unsafe industry practice of 'mounding' tipper lorry loads above side height, combined with inadequate sheeting systems that fail to cover the load, increases the risk of materials falling from vehicles.
Action Planned (AI summary) DVSA will work with HSE to amend load security guidance on GOV.UK to include specific narrative on bulk loads, aiming to have it ready by September 2021. They will arrange special road checks focused on bulk trailer skip lorries, starting in September, and produce dedicated communications highlighting the revised guidance. The company has upgraded its sheeting and restraint systems for all vehicles to increase load cover and security, and is having its Health and Safety Consultants design ongoing training criteria and schedules for drivers.
Parys Lapper
All Responded
2021-0148 10 May 2021 West Sussex
NHS England
Concerns summary (AI summary) A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.
Noted (AI summary) NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve information sharing and mental health services.
Owen Hinds
All Responded
2021-0391 7 May 2021 Nottingham City and Nottinghamshire
Nottingham and Nottinghamshire Clinical…
Concerns summary (AI summary) A significant service gap exists for Autistic Spectrum Disorder patients needing long-term dietetic support for ARFID, as no specialist service is commissioned, causing patients to fall between existing care criteria.
Action Planned (AI summary) The CCG plans to develop an all-age pathway for ARFID patients, including those with ASD, through a working group, patient engagement, and service transformation. They outline a timeline of activities including needs assessment, literature review, pathway development, and workforce training.
Stacey Alexander-Harriss
Historic (No Identified Response)
2021-0145 7 May 2021 East London
Public Health England
Concerns summary (AI summary) Medical professionals lacked awareness of the dangerous bacteria *Capnocytophaga canimorsus* and its risks, coupled with insufficient public awareness for at-risk individuals to seek urgent care after pet bites.
Sarah Brady
All Responded
2021-0224 5 May 2021 Black Country
Sandwell and West Birmingham Hospital T…
Concerns summary (AI summary) A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.
Disputed (AI summary) The hospital disputes that Mrs. Brady was oversupplied with medication, stating that medications were generally supplied for short durations and the dispensed Aspirin was within agreed limits.