Other related deaths
PFD Category
Reports: 778
Areas: 72
Earliest: Aug 2013
Latest: 23 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).
PFD Reports
778 resultsJohn Jaundoo
Historic (No Identified Response)
2017-0100
29 Mar 2017
Liverpool and Wirral
Liverpool City Council
National Offender Management Service
Concerns summary
Probation failed to appropriately place high-risk offenders and maintain dynamic risk assessments, while Adult Social Services lacked oversight, leading to unsuitable placements and missed public protection opportunities.
Antony Abbott
Historic (No Identified Response)
2017-0092
23 Mar 2017
Manchester (West)
Foreign, Commonwealth & Development Off…
Concerns summary
Spanish Custody Officers, despite receiving first aid training for detainees, are not trained in Cardio Pulmonary Resuscitation (CPR), posing a risk in emergency situations.
James Spencer
All Responded
2017-0072
20 Mar 2017
Exeter and Greater Devon
Stoneham Bass
Concerns summary
Inadequate training for induction support officers regarding drug-related collapse and the heightened risks for recently released prisoners due to decreased drug tolerance.
Peter Norton
Historic (No Identified Response)
2017-0251
9 Mar 2017
Cornwall and the Isles of Scilly
Halfords Group PLC
Concerns summary
The store lacked guidance, policies, and risk assessments for cycling indoors, including a safe designated area and helmet use, creating an unsafe environment.
John Atkin
Historic (No Identified Response)
2017-0064
6 Mar 2017
Surrey
Millbrook Healthcare Limited
Concerns summary
There is a critical breakdown in communication regarding hazard assessment at service-user homes, with occupational therapists unaware of their role in informing delivery services about potential dangers, and no policy preventing drivers from entering without prior contact.
Charles Rendell
All Responded
2017-0006
11 Jan 2017
Berkshire
Bayer Plc
Concerns summary
There is inadequate communication to patients and prescribing clinicians about Ciprofloxacin's rare but serious side effect of suicidal ideation. This lack of awareness prevents timely recognition and appropriate reaction to potential symptoms.
Roseleen O’Donoghue
Historic (No Identified Response)
2017-0007
3 Jan 2017
Manchester (South)
Your Housing
Concerns summary
The installed stair lift does not stop in a safe position at the top, leaving the step plate suspended over the stairwell. This creates a falling risk for users and may affect other similar installations.
Simon Charles
All Responded
2016-0465
28 Dec 2016
Cornwall and the Isles of Scilly
South West National Trust
Concerns summary
Concerns exist over insufficient preventative measures at Hells Mouth, a known suicide location, beyond a fence. Suggestions included providing suicide support contact numbers and planting natural barriers along the cliff edge.
Edwin Flett
Historic (No Identified Response)
2016-0450
16 Dec 2016
London Inner (South)
Foreign, Commonwealth & Development Off…
Concerns summary
This beach has an acknowledged high risk of death due to dangerous currents, yet specific warnings for tourists are insufficient, and no standardized risk classification system for swimming is in place.
Pamela Gower
All Responded
2016-0446
15 Dec 2016
County Durham and Darlington
British Parachute Association
Concerns summary
Concerns remain whether the deceased skydiver was progressed beyond her abilities, questioning the adequacy of training intervals and overall progression for such a sport.
Liam Day
All Responded
2016-0402
14 Dec 2016
Dorset
British Mountaineering Council
Royal Yachting Association
Concerns summary
Significant risks in deep water soloing include dangerously cold sea temperatures, lack of essential safety equipment like lifejackets or communication devices, and unawareness of rapid hypothermia.
Ellen Kelly
All Responded
2016-0451
12 Dec 2016
London Inner (North)
London Borough of Camden
Concerns summary
Residential fire safety is compromised by flat front doors lacking self-closing mechanisms and failing to meet 30-minute fire resistance standards, leading to rapid fire spread and trapping residents.
Ajvir Sandhu
Historic (No Identified Response)
2016-0436
8 Dec 2016
North Yorkshire (East)
Department for Transport
Concerns summary
Safety concerns include the lack of mandatory parachutes with static lines in certain aircraft and insufficient mandatory spin recovery training on specific light aircraft types for pilots.
Cameron Forster
Historic (No Identified Response)
2016-0436-wp25563
8 Dec 2016
North Yorkshire (East)
Department for Transport
Concerns summary
Parachutes were not supplied for a light aircraft flight, and there is no mandatory spin recovery training specific to aircraft types, increasing risks during aerobatics.
Andrew Machin
Historic (No Identified Response)
2016-0349
7 Dec 2016
Coventry
National Offender Management Service
Concerns summary
Limited support was provided to a prison employee during a prolonged disciplinary process, and no internal investigation was conducted into the dismissal circumstances following his death.
Flavio Pizarro
Historic (No Identified Response)
2016-0419
23 Nov 2016
Manchester (North)
Canal and River Trust
Concerns summary
Lack of warning signs about swimming dangers and absence of safety aids at canal locks, despite previous assurances, creating ongoing risks for children playing near the water.
Frazer Livesey
All Responded
2016-0418
21 Nov 2016
Cumbria
Impact Housing Association
Concerns summary
Defective window stays prevented emergency escape from inside, potentially contributing to the deceased's death and a friend's injuries.
Gareth Willington
All Responded
2016-wp25435
10 Nov 2016
Carmarthenshire and Pembrokeshire
Maritime and Coastguard Agency
Concerns summary
The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.
Daniel Willington
All Responded
2016-wp25437
10 Nov 2016
Carmarthenshire and Pembrokeshire
Maritime and Coastguard Agency
Concerns summary
The lack of mandatory personal flotation device wearing on fishing vessel decks at sea unnecessarily increases the risk of death.
Michelle Lawrence
Historic (No Identified Response)
2016-0412
8 Nov 2016
London Inner (West)
Metropolitan Police
MOJ
Serco
Concerns summary
Key concerns include lack of independent investigations for deaths after private custody, inadequate concealment questioning, and insufficient strip-search facilities.
Jane Reason
All Responded
2016-0376
25 Oct 2016
Birmingham and Solihull
Department of Health and Social Care
Department for Education
NHS England
+1 more
Concerns summary
There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective use during cardiac arrest.
Isaac Brocklehurst
All Responded
2016-0486
18 Oct 2016
West Yorkshire (West)
Incommunities
Concerns summary
There is a concern about the safety of pedestrian gaps in a low perimeter wall within a communal grassed area, requiring review to protect playing children.
Karnel Haughton
Historic (No Identified Response)
2016-0339
23 Sep 2016
Birmingham and Solihull
National Society for the Prevention of …
Department for Education
Concerns summary
Uncensored online videos promote dangerous 'choking game' activities, yet there is no national guidance for schools or support for parents, risking further injuries and deaths.
Denis Cronin
All Responded
2016-0332
16 Sep 2016
Leicester City and South Leicestershire
British Sub Aqua Club
Dulwich Dive Club
Concerns summary
Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment design posed a release risk.
David Phillips
Historic (No Identified Response)
2016-0334
16 Sep 2016
Swansea Neath and Port Talbot
Mitie
NHS Wales
South Wales Police
Concerns summary
An inappropriate healthcare professional conducted the mental health assessment for a vulnerable older person, and the assessing professional lacked critical access to the detainee's medical records.