Other related deaths

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

75% response rate (above 62% average). 46% 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 46%
Action Planned 31%
Noted 16%
Disputed 7%
Based on 318 classified responses
Reports by Quarter
Clear
PFD Reports
477 results
Adam Johnson
All Responded
2023-0427 3 Nov 2023 South Yorkshire (Western)
Ice Hockey UK English Ice Hockey
Concerns summary The International Ice Hockey Federation does not mandate neck guards for adult players, raising concern that this lack of required protective equipment could lead to future deaths.
Action taken summary England Ice Hockey, Ice Hockey UK, and Scottish Ice Hockey have mandated the wearing of neck laceration protectors for all players and coaches in all forms of ice hockey in the UK from January 1, 2024
Frederick Powell
All Responded
2023-0406 24 Oct 2023 Lincolnshire
Acis Housing
Concerns summary Many properties still contain internal glass doors, raising safety concerns and prompting a review of replacement policies, even if current building regulations are met.
Action taken summary Acis Group has commenced a comprehensive review of its policy and approach to internal doors with non-toughened glazing across its housing stock, with recommendations to be presented to its Board in S
Jill Brice
All Responded
2023-0401 20 Oct 2023 West Sussex, Brighton and Hove
Department for Housing Care Quality Commission
Concerns summary Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.
Action taken summary The Care Quality Commission (CQC) has identified that the accommodation where Mrs. Brice resided is not registered with or regulated by them. They have requested further information and an extension t
Trevor Bailey
All Responded
2023-0419 20 Oct 2023 Inner North London
Church Lane Surgery Northwick Park Hospital
Concerns summary The emergency department failed to elicit crucial patient history, such as smoking and family cardiac issues, which should have prompted a life-saving referral to a rapid access chest pain clinic.
Action taken summary The Trust disputes that the patient would have met the criteria for referral to the rapid access chest pain clinic, even with additional risk factors. However, as part of ongoing improvements, they in
Claire Twinn
All Responded
2023-0386 16 Oct 2023 East London
Department of Health and Social Care Bart Health NHS Foundation Trust
Concerns summary Sub-optimal care for a disabled patient included a lack of reasonable adjustments for communication, unrecorded discharge decisions, absence of specialist learning disability nursing, and a critically delayed radiological report.
Action taken summary Barts Health NHS Trust has developed a new SOP for patients with learning disabilities in the Emergency Department, ensuring printed discharge letters and ongoing audits. The Trust has also implemente
Iain Farrell
All Responded
2023-0407 13 Oct 2023 Dorset
National Coasteering Charter
Concerns summary Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to inaccessible communication, and inadequate assessment of participant swimming ability or fitness.
Action taken summary The National Coasteering Charter (NCC) will update its ‘Safety Advice for Coasteering Providers 2015 Version 3’ document to address concerns about lone guiding. An action plan outlines consultation wi
Alex Dews
All Responded
2023-0380 10 Oct 2023 South Yorkshire (Western)
Department for Education Department of Health and Social Care
Concerns summary School avoided NHS mental health referrals due to excessive waiting lists, instead procuring private support with unclear allocation processes and poor communication between the school and external providers.
Action taken summary The academy has allocated a key member of the Inclusion team to manage all external referrals for mental health support. They plan to provide training on new referral flow-charts and establish clearer
Sandra Curran
All Responded
2023-0378 9 Oct 2023 Manchester South
ABTA – The Travel Association Foreign, Commonwealth & Development Off…
Concerns summary UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea swimming and snorkelling in unfamiliar locations with strong currents.
Action taken summary ABTA explains its role as a trade association providing guidance to members and consumers. They detail existing consumer safety information leaflets and 'WaterWise' campaigns that promote swim safety,
Kirandip Bharaj
All Responded
2023-0379 9 Oct 2023 Blackpool & Fylde
Blackpool Council
Concerns summary Adult social care staff lack the tools, training, and guidance to recognise and act on concerning signs of eating disorders, risking unaddressed, urgent medical needs for vulnerable service users.
Action taken summary Blackpool Council has commenced an internal review into the incident and plans to share learning across services. They have outlined a series of planned actions including exploring a specific risk ass
Kellie Poole
All Responded
2023-0364 4 Oct 2023 Derby and Derbyshire
Health and Safety Executive
Concerns summary There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.
Action taken summary The Health and Safety Executive disputes the need for specific guidance for cold water immersion providers, stating that existing health and safety legislation and guidance from other authoritative so
Marcel Wochna
All Responded
2023-0332 14 Sep 2023 Hampshire, Portsmouth and Southampton
Hampshire & Isle of Wight Constubulary
Concerns summary Police staff lacked critical awareness of cold water shock, water rescue procedures, and the risks of handcuffing near water, alongside poor dissemination of relevant safety protocols.
Action taken summary Hampshire Constabulary has produced an updated 'Working Near Water Procedure' that now properly describes Cold Water Shock and the 'Shout, Reach, Throw, Row, Go' method. They will update their E-Learn
Lynsey Smalley
All Responded
2023-0322 8 Sep 2023 North West Wales
Barts Health NHS Foundation Trust
Concerns summary Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost notes and poor continuity of patient care.
Action taken summary The Health Board has updated its Serious Incident Policy to include clear timescales. It is currently developing a Quality Governance Improvement Plan for its Mental Health and Learning Disabilities D
Lamont Roper
All Responded
2023-0381 7 Sep 2023 North London
Metropolitan Police Service
Concerns summary Concerns include insufficient and cumbersome water rescue equipment for police, inadequate training for cycle patrols near water, and limited awareness of dive team availability and capacity.
Action taken summary The Metropolitan Police Service reviewed and refreshed its cycle training at the beginning of 2022, implementing a policy in April 2023 that requires officers to complete this training before operatio
Emma Morrissey
All Responded
2023-0317 4 Sep 2023 Cheshire
Regenesis Health Travel Limited
Concerns summary Health tourism company failed to adequately assess patient fitness for surgery abroad, using unclear pre-assessment questions. There was no investigation into the operating table death, and embalming and medical reporting were inadequate.
Action taken summary The UK Government expressed concerns to the Turkish Ministry of Health and its officials are investigating issues surrounding global medical tourism, including consultations with relevant stakeholders
Mizanur Rahman
All Responded
2023-0306 29 Aug 2023 Inner North London
Product Safety and Standards
Concerns summary A lack of British or European safety standards for lithium-ion e-bike batteries and chargers allows unsafe products to be sold and mixed, causing fires, thermal runaway, and multiple deaths.
Action taken summary The Office for Product Safety and Standards has established a multi-disciplinary safety study, commissioned new research into battery safety, and engaged with the London Fire Brigade. They also publis
Lawson Bond
All Responded
2023-0335Deceased 22 Aug 2023 Worcestershire
Wychavon District Council
Concerns summary Worcestershire Regulatory Services' lack of proactive monitoring for unlicensed dog breeders on websites allows unscrupulous sellers to operate undetected, increasing the risk of dangerous puppies being sold to the public.
Action taken summary Wychavon District Council will implement continuous, business-as-usual intelligence gathering for a minimum of 12 months, monitoring a significantly larger number of online selling sites for unlicense
Luke Brooks
All Responded
2024-0326 17 Aug 2023 Manchester North
Communities & Local Government Department of Health and Social Care Ministry of Housing
Action taken summary North West Ambulance Service has revised its 111 service policy for self-conveyance, removing all exclusions except for Category 1 incidents and requiring advisors to ask patients if they can self-con
Barry Lall
All Responded
2023-0385 15 Aug 2023 Central and South East Kent
General Dental Council
Concerns summary The General Dental Council's practice of publishing extensive, detailed allegations on its website for unconcluded cases can cause significant mental health distress to practitioners who are contesting them.
Action taken summary The General Dental Council is undertaking and has prioritised a review of its policy regarding the publication of details for interim order determinations, including the extent of information and whet
Rohan Godhania
All Responded
2023-0289 9 Aug 2023 Milton Keynes
NHS England and NHS Improvement Food Standards Agency
Concerns summary High protein supplements lack adequate warning labels for individuals with undiagnosed urea cycle disorders, risking severe medical emergencies due to sudden protein intake.
Action taken summary NHS England has issued a Patient Safety Bulletin highlighting the need for prompt ammonia measurement in hyperammonaemia and is committed to a '0-25 year service model' for young people. They have dev
John Shenton
All Responded
2023-0282 2 Aug 2023 Shropshire, Telford and Wrekin
Range
Concerns summary Outstanding recommendations for escalator safety, particularly for vulnerable individuals when lifts are unavailable, were not acted upon, indicating insufficient measures to protect users.
Benjamin McQueen
All Responded
2023-0285 28 Jul 2023 London City
Ministry of Defence
Concerns summary Military diving training had critical safety shortcomings, including no spare breathing gas for standby divers, inappropriate acceleration of training, lack of readily available defibrillators, and inconsistent safety pressure guidelines.
Action taken summary The Ministry of Defence has implemented revised medical policies (JSP800), updated diving policy (JSP286) to instruct specific checks by dive team leaders, and embedded additional training following a
Paul Keating
All Responded
2023-0279 25 Jul 2023 West Yorkshire (Eastern)
Leeds City Council Home Office
Concerns summary The local authority lacked statutory power to install sprinkler systems in private flats without consent, leading to one resident's flat remaining unconnected, which likely contributed to his fire-related death.
Action taken summary Leeds City Council acknowledges and endorses the coroner's concern regarding the lack of legal powers for landlords to access private dwellings without tenant consent for fire safety improvements. The
John Coles
All Responded
2023-0271 24 Jul 2023 West London
Heathrow Airport
Concerns summary Visual interference as a potential accident factor was not adequately considered or accepted, and the visibility of vehicles at uncontrolled crossings lacked sufficient safety measures and oversight.
Action taken summary Heathrow Airport Limited has commissioned an assessment by the Transport Research Laboratory (TRL) and is planning to revise and enhance airside driver training materials by Q3 2024 to include visual
Sylvia Pollitt
All Responded
2023-0258 19 Jul 2023 Manchester South
L&Q Group Housing
Concerns summary The Housing Association lacked an audit system to ensure subcontractors escalated non-contact referrals for welfare checks and failed to monitor referral outcomes, missing crucial safety oversight for vulnerable adults.
Action taken summary L&Q has implemented new processes to ensure all contractor repair calls are recorded and tracked through a central call centre system, providing an auditable trail. They have also instituted weekly me
Ross Ballatine, Carl McGrath, Alan Minard
All Responded
2023-0245 17 Jul 2023 North Wales East and Central
Maritime & Coastguard Agency
Concerns summary The agency failed to adequately assess vessel stability after significant modifications, relying on inadequate checks and skipper assurances, leading to a risk of other unassessed modified vessels operating unsafely.
Action taken summary The Maritime Coastguard Agency implemented a new Fishing Vessel Stability Policy (MCA Policy 445) and an Inspection Policy (MCA Policy 444) in May and July 2023 respectively, clarifying stability asse