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).
PFD Reports
778 resultsJoan Hoggett
All Responded
2022-0141
City of Sunderland
Concerns summary
The Mental Health Trust's ability to engage with a perpetrator was severely hampered by insufficient capacity and resources, especially during periods of staff absence.
Action taken summary
The Trust is planning further improvement work in 2022/23 to increase staff time with service users and carers, including stakeholder engagement and reviewing "Getting to Know You" documentation. They
Khalid Yousef
All Responded
2022-0193
Birmingham and Solihull
Birmingham and Solihull Mental Health
Home Office
West Midlands Police
+1 more
Concerns summary
Police custody L&D services lack commissioned psychiatrists, leaving junior staff unable to adequately assess serious mental illness. This is compounded by misunderstanding of L&D's role and a reduction in qualified Forensic Medical Examiners.
Action taken summary
West Midlands Police has instructed the creation of a formal escalation process for Liaison and Diversion (L&D) decisions, a review of mental health training for custody officers/staff, and the provis
Hannah Booth
All Responded
2025-0615
Derby and Derbyshire
NHS Derby & Derbyshire Integrated Care …
NHS England
Sett Valley Medical Centre
+2 more
Concerns summary
Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.
Action taken summary
The Trust has audited GPs not using SystmOne, drafted an information leaflet for GPs, and added learning to a stakeholder event agenda. They are also implementing system alerts for patients whose GPs