Other related deaths

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

75% response rate (above 62% average). 48% 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 48%
Action Planned 30%
Noted 15%
Disputed 7%
Based on 543 classified responses
Reports by Quarter
PFD Reports
776 results
Matthew Willoughby
All Responded
2020-0016 19 Jan 2020 Blackpool & Fylde
Landlord
Concerns summary A landlord failed to ensure safety adaptions, such as window restrictors, remained in place after a tenant removed them, despite prior safety advice. This created a serious ongoing risk to tenants.
Colin North
All Responded
2020-0003 9 Jan 2020 Birmingham and Solihull
Incarace ORCi
Concerns summary There is a severe lack of pedestrian control on race tracks immediately post-race, with active vehicles and no designated safe zones or walkways. Risk assessments are inadequate for both pedestrians and staff on the track.
Enid Baber
Historic (No Identified Response)
2020-0120 27 Dec 2019 Nottinghamshire and Nottingham
Nottinghamshire County Council
Concerns summary Nottinghamshire County Council failed to routinely assess for deprivation of liberty in community settings, and staff lacked training in this complex area, potentially leaving vulnerable individuals without adequate human rights safeguards.
Henry Campbell-Byatt
Historic (No Identified Response)
2019-0438 16 Dec 2019 London Inner (West)
Peligoni Club
Concerns summary The resort lacked essential deep-water rescue equipment and trained staff. The system for monitoring swimmers was inadequate, necessitating improved watchtower manning and safety equipment.
Matthew Fitten
All Responded
2020-0275 7 Dec 2019 Suffolk
General Pharmaceutical Council and Have… Public Health England
Concerns summary A change in methadone prescription to larger bottles, without providing a measuring jug, likely led to inaccurate dosing and a fatal overdose.
Maureen Milton
All Responded
2019-0396 22 Nov 2019 Staffordshire (South)
Trent and Dove Social Housing Care Quality Commission National Institute for Health and Care … +3 more
Concerns summary There is insufficient awareness among healthcare professionals and carers about the severe fire risk posed by petrol-based emollient creams, which impregnate clothing and accelerate burns.
Jonathan Adebanjo
Historic (No Identified Response)
2019-0399 22 Nov 2019 London Inner (North)
London Borough of Tower Hamlets
Concerns summary Swimming prohibition signs are too small and lack detail regarding specific dangers like poor visibility, undercurrents, and submerged debris.
Evha Jannath
Historic (No Identified Response)
2019-0368 13 Nov 2019 Staffordshire (South)
Drayton Manor Theme Park Merlin Entertainment Limited
Concerns summary The ride suffered from inadequate CCTV monitoring due to staffing issues, lack of clear safety warnings to guests, poor signage, and no staff training or equipment for water rescue, alongside unclear emergency procedures.
London Bridge & Borough Market Terror Attack
All Responded
2019-0332 1 Nov 2019 London Inner (South)
City of London Police British Vehicle Rental and Leasing Asso… Department for Transport +6 more
Concerns summary The provided text outlines the coroner's duty to report matters of concern but does not detail any specific safety issues or systemic failures.
Douglas Oak
All Responded
2019-0352 24 Oct 2019 Dorset
Dorset Police Association of Ambulance Chief Executiv… National Ambulance Service Medical Dire… +3 more
Concerns summary There is a critical lack of national guidance for Ambulance Services on using chemical sedation for patients with Acute Behavioural Disturbance, despite its effectiveness for safe treatment and transport.
Cesar Gonzalez Barron
Historic (No Identified Response)
2019-0342 14 Oct 2019 London Inner (North)
First Aid Cover Limited Roundhouse White Branch Live Limited
Concerns summary Multiple failures in event first aid included delayed recognition of collapse, inadequate first aider briefing and knowledge of venue protocols, poor communication, and a chaotic scene that delayed CPR and ambulance access.
James Frankish
Partially Responded
2019-0468 9 Oct 2019 Nottinghamshire
British Psychological Society Royal College of Paediatrics and Child … Royal College of Physicians +5 more
Concerns summary Healthcare professionals lacked understanding of Pica's dangers, and there is no national guidance for its identification, assessment, management, or monitoring for complications like bezoars.
Philip Owen
All Responded
2019-0330 2 Oct 2019 Manchester (South)
MOJ
Concerns summary Challenges exist in safely releasing high-risk offenders after short custodial sentences, compounded by limited probation supervision and unclear communication of risks or guidance to sentencing courts.
Owen Carey
All Responded
2019-0335 30 Sep 2019 London Inner (South)
British Society for Allergy and Clinica… Byron Hamburgers Department of Environment +4 more
Concerns summary The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to clearly state key allergen information, creating false reassurance for customers.
Anna Hedman
Historic (No Identified Response)
2019-0321 25 Sep 2019 London Inner (West)
Metropolitan Police
Concerns summary A police call handler's inadequate training led to a gross failure to prioritize preservation of life and call an ambulance, even when prompted, in an emergency situation.
Kristiyan Danailov
Historic (No Identified Response)
2019-0315 23 Sep 2019 Dorset
Chemical Business Association Department for Environment Food and Rural Affairs +1 more
Concerns summary Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack of industry awareness about associated risks.
Lucia Stear
All Responded
2019-0296 13 Sep 2019 Liverpool and Wirral
Communities & Local Government Department of Housing
Concerns summary Other public authorities may have unaddressed safety issues similar to Wirral MBC's tree management, necessitating national learning and action from the tragic death.
Carl Schmidt
All Responded
2019-0358 11 Sep 2019 West Yorkshire (East)
University of Birmingham
Concerns summary The chemo-radiotherapy in a clinical trial potentially exposes patients to neurological damage, requiring further investigation into the mechanism of injury.
Michael Hoolickin
All Responded
2019-0292 29 Aug 2019 Manchester (North)
National Probation Service Lancashire Constabulary National Police Chiefs’ Council +2 more
Concerns summary No specific safety concerns or systemic failures were detailed beyond the general mention of "Serious Further Offence Reviews" needing to be conducted.
Kay Martin
All Responded
2019-0262 27 Aug 2019 Sunderland
Home Office
Concerns summary A perpetrator of domestic abuse was not subject to any police bail conditions or restrictions for over a month, leaving the victim unprotected and at severe risk.
George Rimmer
All Responded
2019-0269 16 Aug 2019 West Sussex
Boehringer Ingelheim Limited
Concerns summary Inadequate patient counselling and insufficient warnings on medication packaging failed to address the dangers of exceeding doses, self-medicating, and unmeasured consumption.
Christopher Hart
All Responded
2019-0272 14 Aug 2019 Manchester (South)
Johnnie Johnson Housing
Concerns summary The housing provider failed to impose fire safety standards for tenant furniture and did not review sprinkler system installation, despite evidence of their life-saving potential.
Stanislawa Kmiecik
All Responded
2019-0258 25 Jul 2019 Nottinghamshire
URBN UK Ltd
Concerns summary An accessible mezzanine area with an 18-foot drop lacked adequate safety measures, including proper signage, secure barriers, safety netting, and presented trip hazards due to an uneven surface, risking falls for staff and the public.
Owen Williams
Partially Responded
2019-0250 25 Jul 2019 West Yorkshire (West)
Department for Education Sixth Form Colleges Association Universities and Colleges Admissions Se…
Concerns summary The electronic release of A-level results at 6:00 am, hours before student support was available, left vulnerable students without immediate guidance, contributing to a tragic outcome after disappointing grades.
Cherylee Shennan
Partially Responded
2019-0244 19 Jul 2019 Lancashire & Blackburn with Darwen
Lancashire Constabulary HM Prison and Probation Service MOJ
Concerns summary Insufficient inter-agency communication and a lack of mandatory information sharing protocols for MAPPA Level 1 offenders with domestic abuse histories persist, despite known risks and previous reviews.