Other related deaths

PFD Category
Reports: 778 Areas: 72 Earliest: Aug 2013 Latest: 23 Mar 2026

75% response rate (above 62% average). 47% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).

Response Status
Responded 581 No Response 4 Historic 163 Pending 14
AI Classification
Action Taken 47%
Action Planned 31%
Noted 15%
Disputed 8%
Based on 714 classified responses
Reports by Quarter
PFD Reports
778 results
Gerardo Tonogbanua
Historic (No Identified Response)
2014-0245 27 May 2014 Avon
British Standards Institution Maritime and Coastguard Agency Department for Transport
Concerns summary A rescue boat's fall wire failed due to an overstressing winch, highlighting a lack of 'system' design consideration in regulations. An electronic safety switch also failed, exacerbated by vague guidance on safety device performance.
Christian Devereux
All Responded
2014-0240 23 May 2014 Rutland & North Leicestershire
RAC Motorsports Association
Concerns summary A HANS type device likely would have prevented or reduced fatal head and neck injuries in a collision. Many drivers in the race were not using these affordable and beneficial safety devices.
Josephine Foday
All Responded
2014-0301 23 May 2014 Essex
Chartered Institute of Environmental He…
Concerns summary The pool's inherently dangerous profile was not properly risk-assessed. A lack of lifeguards, unmonitored CCTV, unclear signage, and untrained staff in aquatic rescue created significant drowning risks, especially for non-swimmers.
Komba Kpakiwa
Partially Responded
2014-0301-wp24615 23 May 2014 Essex
Institute of Occupational Safety and He… Chartered Institute of Environmental He…
Concerns summary The pool had an inherently dangerous profile with inadequate risk assessments, no lifeguards, ineffective supervision (unmonitored CCTV), unclear signage, and untrained staff in aquatic rescue.
Amanda Richards
All Responded
2014-0228 12 May 2014 Coventry
Whitefriars Housing
Concerns summary The absence of domestic sprinkler systems in special accommodation, like Ms Richards', significantly increased the risk of death from fire.
Ernest Harper
All Responded
2014-0223 9 May 2014 Bedfordshire & Luton
Bedford Borough Council
Concerns summary Design flaws allowed falling between the safety barrier and vehicle, compounded by the lack of formal assessment for passenger health and mobility for safe access.
Sopefoluwa Peters
All Responded
2014-0206 8 May 2014 County Durham & Darlington
Durham County Council
Concerns summary Hazardous steps, poorly illuminated and without a handrail, combined with a low riverside safety barrier, created a dangerous environment, especially for intoxicated individuals.
Sidney Martin
All Responded
2014-0196 1 May 2014 North Yorkshire (West)
North West Waterways Canal & River Trust
Concerns summary The dangerous condition of canal bridge steps and poor lighting in the area pose a significant risk to public safety.
Muriel Dawson
Partially Responded
2014-0173 17 Apr 2014 West Yorkshire (West)
Optare Vehicle Operator Services Agency Transport Research Laboratory
Concerns summary The bus design lacked restraints for seated passengers, especially in the aisle seat, leading to fatal injury during a sudden stop. Type-approval may not adequately consider the risk of death or serious injury.
Lorna Cullen
Historic (No Identified Response)
2014-0105 11 Mar 2014 Mid Kent & Medway
NHS Swale Clinical Commissioning Group NHS Medway Clinical Commissioning Group
Concerns summary Inadequate staffing levels for liaison psychiatry nurses in hospital emergency departments led to dangerously long wait times for mental health assessments, hindering timely risk identification and management for vulnerable patients.
Kathleen Border
All Responded
2014-0095 4 Mar 2014 Portsmouth & South East Hampshire
Northwood Square
Concerns summary Inadequate and unclear signage for parking areas led to a delivery vehicle reversing outside a designated zone, causing a fatal collision.
Ryan Pettengell
Historic (No Identified Response)
2014-0096 4 Mar 2014 Norfolk
Norfolk Police Norfolk County Council Borough Council of King’s Lynn & West N… +1 more
Concerns summary Despite official closure and prior safety recommendations following multiple drownings, the site remains accessible to the public with damaged/missing signage and no implemented safety improvements.
Carl Morris
All Responded
2014-0092 3 Mar 2014 Cumbria (North & West)
Professional Association of Diving Inst…
Marco Lima De Araujo
All Responded
2014-0093 3 Mar 2014 Portsmouth & South East Hampshire
Queen’s Harbour Master Portsmouth
Concerns summary There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Richard White
All Responded
2014-0085 28 Feb 2014 County Durham & Darlington
700 Club
Concerns summary Hope House lacked a formal, documented policy or protocol for medication administration, which was unknown to prescribers and not made available to staff.
Sidney Harvey
Historic (No Identified Response)
2014-0075 26 Feb 2014 South Lincolnshire
South Kesteven District Council
Concerns summary Non-safety glass doors in rented properties, particularly where vulnerable individuals reside, pose a risk, and there is no clear system for their replacement or safety upgrade.
Bertram Hamilton
Historic (No Identified Response)
2014-0080 26 Feb 2014 Black Country
Nursing and Midwifery Council
Concerns summary A nurse administered insulin to a patient with dangerously low blood sugar, demonstrating a critical lack of understanding regarding insulin administration protocols.
Rachel Burke
Partially Responded
2014-0074 25 Feb 2014 London (Inner South)
Himalayan Encounters Adventure Company Ministry of Culture +3 more
Concerns summary An adventure company misrepresented ascent altitudes, leading to unsafe rates for altitude sickness prevention. The trek leader prioritized cost over urgent medical care and failed to appreciate illness severity due to inadequate training.
John Davies
Historic (No Identified Response)
2014-0063 13 Feb 2014 London Inner (West)
General Medical Council Royal College of Physicians Medical Protection Society
Concerns summary GMC investigations are causing unrecognised psychological distress in clinicians, underscoring the need for improved communication, support resources, and proactive assessment for suicidal or self-harming behaviours.
Brian Kent
Historic (No Identified Response)
2014-0053 6 Feb 2014 London (South)
Italian Embassy
Concerns summary No specific concerns are detailed in the provided text.
Neil Blood
Historic (No Identified Response)
2014-0183 4 Feb 2014 Stoke-on-Trent & North Staffordshire
Department for Transport Shimano Inc
Concerns summary A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns about potential dangers to users.
Ryan Clark
All Responded
2014-0057 3 Feb 2014 West Yorkshire (East)
National Offender Management Service
Concerns summary Prison procedures like the Personal Officer Scheme, ACCT checks, and roll call were not properly implemented. Additionally, prison officers lacked sufficient first aid and CPR training.
Tallulah Wilson
All Responded
2014-0047 30 Jan 2014 London Inner (North)
Department of Health and Social Care
Concerns summary Healthcare professionals lacked sufficient understanding of young people's evolving internet use and online lives. Digital lives training is not standard for psychiatric or medical inductions.
Action taken summary The Department of Health has launched an e-learning tool for professionals working with children and young people on mental health. They are also funding research into internet use and suicidal behavi
Elizabeth Turnbull
Historic (No Identified Response)
2014-0035 24 Jan 2014 South Yorkshire (East)
British Industrial Truck Association HM Principle Specialist Inspector
Concerns summary The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently releasing locking pins for excavator attachments.
William Dowling & Victoria Rose
Historic (No Identified Response)
2014-0027 21 Jan 2014 Wiltshire & Swindon
Minister of State for Victims and Sente… Wiltshire Clinical Commissioning Group Wiltshire Constabulary +2 more
Concerns summary There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms license, with patient confidentiality potentially overriding public safety.