Other related deaths

PFD Category
Reports: 783 Areas: 72 Earliest: Aug 2013 Latest: 14 Apr 2026

76% response rate (above 63% average). 34% of classified responses show concrete action taken. Reports fell 26% from 91 (2023) to 67 (2024).

Response Status
Responded 592 No Response 10 Historic 174 Pending 3
AI Classification
Action Taken 34%
Action Planned 40%
Noted 24%
Disputed 1%
Based on 1,081 classified responses
Reports by Quarter
PFD Reports
783 results
Jonathan Goldstein, Hannah Goldstein and Saskia Goldstein
All Responded
2023-0514 5 Dec 2023 Inner South London
UK Civil Aviation Authority
Concerns summary (AI summary) A critical lack of compulsory mountain flying training and guidance for UK PPL(A) license holders means pilots undertake hazardous flights without adequate knowledge of specific risks and tactics.
Action Planned (AI summary) The CAA acknowledges the challenges of mountain flying and states it will publish relevant guidance on its website by 31 July 2024, and a Safety Sense Leaflet on mountain flying by 31 December 2024.
Donna Donnellan
All Responded
2023-0493 30 Nov 2023 Manchester North
Northern Care Alliance Pennine Care NHS Trust
Concerns summary (AI summary) A lack of clarity exists between Acute and Mental Health Trusts regarding the Mental Health Liaison Team's role and appropriate referral pathways to specialist eating disorder services.
Action Taken (AI summary) The Trust has finalised and ratified the policy 'Management of Medical Emergencies in Adult Patients with Eating Disorders' and shared it with Pennine Care NHS FT. The policy clarifies roles, responsibilities, and referral pathways. The Trust has worked with Northern Care Alliance NHS Foundation Trust to review policies and procedures following the Inquest, to add clarity regarding referral. The learning from this inquest and the policy detail has been shared with the appropriate teams by managers to support understanding.
Benn Curran-Nicholls
Partially Responded
2023-0480 27 Nov 2023 Manchester City
Manchester City Council UK Health Security Agency
Concerns summary (AI summary) An unspecified risk of death exists in similar circumstances; public awareness, especially for child carers, is crucial to reduce these risks.
Action Taken (AI summary) UKHSA highlighted the risk of ingesting yew tree berries to Directors of Public Health across the NW and to the other eight English regions and Devolved Administrations; shared general resources that can be shared with residents.
Gracie Spinks
All Responded
2023-0479 27 Nov 2023 Derby and Derbyshire
Derbyshire Constabulary Home Office
Concerns summary (AI summary) Derbyshire Constabulary showed serious failings in investigating stalking, with inadequate officer training and understanding, alongside a lack of comprehensive and ongoing risk assessments.
Action Planned (AI summary) The Home Office is exploring with stakeholders where Government intervention could improve the criminal justice response to stalking and support for victims, including within the Victims and Prisoners Bill; officials will review statutory guidance on coercive and controlling behaviour and work with the NPCC to gather examples of best practice in policing stalking cases. Derbyshire Constabulary has updated training and guidance, reinforced requirements for record keeping, and reviewed policies regarding found weapons, including issuing specific policy relating to found weapons in October 2023.
Jane Bennett
All Responded
2023-0495 24 Nov 2023 Nottingham City and Nottinghamshire
Mansfield District Council
Concerns summary (AI summary) Mould in council-owned properties, including the deceased's, poses a risk to tenant health, requiring urgent inspection and action to minimize exposure.
Action Taken (AI summary) The council has updated its website to provide further guidance on damp, mould and condensation, trialling environmental monitoring devices for placement in tenant’s homes, increased the capacity of the inspection team and contractors, and procured mould kits for tenant usage. It has also updated its triage system with scripted prompts for all reported damp, mould and condensation cases reported by the tenant.
Zulfiqar Hussain
All Responded
2023-0476 24 Nov 2023 Manchester North
Croft Shifa Health Centre
Concerns summary (AI summary) Administrative staff handle GP correspondence without robust medical oversight, and adverse medication markers are missing from records, risking contraindicated prescriptions and inadequate patient care.
Action Taken (AI summary) The practice reviewed its document management in Nov 2021 and updated its Document Management Policy to include suspected cancer referrals, learning disabilities, mental health/depression, safeguarding notifications, addiction and patients on Gold Standard Framework to be sent to GPs. An alert was added to Mr Hussain's record alerting clinicians to potential medication misuse.
Kevin O’Hara
All Responded
2023-0472 23 Nov 2023 Surrey
Surrey County Council
Concerns summary (AI summary) Inexperienced staff conducting Safe and Well Visits without audit or oversight, coupled with a lack of consistent risk assessment follow-ups, results in missed opportunities to identify and address safety issues.
Action Planned (AI summary) Surrey County Council and Surrey Fire and Rescue Service acknowledge mistakes and outline planned improvements. These include quality assurance for Safe and Well Visits, a new risk assessment process within Adult Social Care, and updated training programs with timelines provided.
Claire Homer
All Responded
2023-0448 10 Nov 2023 Inner North London
Camden and Islington NHS Foundation Tru…
Concerns summary (AI summary) The absence of robust protocols for managing patient deterioration when key staff are on leave, or both contacts are absent, led to a critical email going unanswered, resulting in delayed care.
Action Taken (AI summary) Barnet, Enfield and Haringey Mental Health Trust discussed out-of-office responses and escalation procedures with staff, issued a template for out-of-office replies, ensured voicemail messages follow the same practice, updated online information with duty mobile numbers, reiterated the need for clear doctor cover arrangements, and emphasised the importance of balancing service needs with leave requests and clear patient handovers.
Graham Coombe
All Responded
2023-0440 10 Nov 2023 East Sussex
Concerns summary (AI summary) Emergency access to the pier was obstructed by a locked gate and unavailable key. Additionally, life-saving rings were hidden, had insufficient rope length for low tide, and were inadequate in number.
Action Taken (AI summary) The pier has replaced locks on the gates with digital locks, notified Sussex Police, the Coastguard and ESF&R of the gate codes, increased the length of the ropes on the life saving rings to 50 metres and ensured that all rings are easily visible and accessible.
Lee Bowman
All Responded
2024-0109 8 Nov 2023 South Yorkshire East
College of Policing
Concerns summary (AI summary) Police made significant assumptions about a missing person, focusing on past addiction rather than prioritizing crucial family information regarding his current mental state and usual daily contact.
Action Planned (AI summary) The College of Policing will update its Missing Persons APP to alert police officers and staff to the need to avoid imprecise terms such as 'chaotic lifestyle' and instead set out clearly what matters and issues have been identified that have a bearing on the assessment of risk.
Owen Garnett
Historic (No Identified Response)
2023-0434 8 Nov 2023 Warwickshire
Health and Safety Executive Unity MAT
Concerns summary (AI summary) A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying and escalating health and safety issues.
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Partially Responded
2023-0467 7 Nov 2023 Derby and Derbyshire
Capita Chief Probation Officer for England and… Derbyshire Healthcare NHS Foundation Tr… +1 more
Concerns summary (AI summary) Probation Service offender records lacked clear, prominent recording of critical risk information, leading to unread vital details and insufficient domestic abuse and child safeguarding checks. Systemic issues contributed to ongoing risks.
Action Taken (AI summary) Phoenix Futures will send a Probation Feedback Form within 48 hours of attended appointments and 24 hours of failed appointments and will conduct monthly audits of compliance. HMPPS is updating guidance on Drug Rehabilitation Requirements (DRR) and Alcohol Treatment Requirements (ATR), and has launched new joint working arrangements detailing the roles and responsibilities of both the Probation Service (PS) and Treatment Providers (TPs) in the East Midlands in Derby and Derbyshire. Capita reinforced safeguarding requirements, created a mandatory training module, and implemented a 'clear chain notification' (CCN) for reporting potential risk of harm. The contract with MOJ ends 30 April 2024 and is being taken over by Serco.
Adam Johnson
All Responded
2023-0427 3 Nov 2023 South Yorkshire (Western)
Elite Ice Hockey League English Ice Hockey Horwich Farrelly Limited +1 more
Concerns summary (AI 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.
Noted (AI summary) England Ice Hockey along with Ice Hockey UK (IHUK) and Scottish Ice Hockey (SIH), confirm the mandating of neck laceration protectors which comes into effect from 1st January 2024. The EIHL will mandate the use of neckguards for all players from 1 January 2024 in training and games, and a temporary rule change has been put in place to sanction non-compliance pending the provision of the full rule change from the IIHF. Ice Hockey UK describes its role as the national governing body and notes that the IIHF has mandated neck guards at all levels of competition. They state that IHUK mandated neck guards for Senior Men and Women with immediate effect on 30 October 2023, in addition to the existing mandate for the U16, U18 and U20 categories. England Ice Hockey provides information about regulations around neck laceration protection and the governance structure of Ice Hockey in the UK, but does not commit to specific actions beyond what is already recommended.
Musa Konteh
Historic (No Identified Response)
2023-0426 1 Nov 2023 Inner North London
Consular Feedback Team
Concerns summary (AI summary) Jet ski hire operations had virtually no health and safety procedures, lacking instructions on emergency cut-offs, warnings for hazards, and failing to provide lifejackets.
Carl Fullalove
Partially Responded
2023-0408 25 Oct 2023 Cheshire
College of Policing National Police Chiefs Council
Concerns summary (AI summary) Inadequate police training on identifying nuanced symptoms of Acute Behavioural Disturbance (ABD) and the risks of prone restraint for drug-intoxicated individuals led to fatal outcomes.
Action Taken (AI summary) The College of Policing updated their First Aid Learning Programme (FALP) in April 2024 to include updated guidance on Acute Behavioural Disturbance (ABD), including de-escalation and communication strategies.
Frederick Powell
All Responded
2023-0406 24 Oct 2023 Lincolnshire
Acis Housing
Concerns summary (AI 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.
Noted (AI summary) Acis Group acknowledges the coroner's concerns, referred the issue to the Regulator of Social Housing and the National Housing Federation, and raised awareness within the social housing sector, asserting no breach of regulatory standards or statutory obligations.
Trevor Bailey
All Responded
2023-0419 20 Oct 2023 Inner North London
Church Lane Surgery Northwick Park Hospital
Concerns summary (AI 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.
Noted (AI summary) Church Lane Surgery updated their patient history templates, provided training to staff on collecting and recording family history of IHD, and restructured the on-call system for the Duty doctor by adding un-booked telephone and face-to-face slots. London North West University Healthcare NHS Trust argues that the patient's management in the emergency department was appropriate based on national scoring and existing chest pain pathways and describes the introduction of an Emergency Assessment Unit designed to improve waiting times.
Jill Brice
All Responded
2023-0401 20 Oct 2023 West Sussex, Brighton and Hove
Care Quality Commission Department for Housing
Concerns summary (AI summary) Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.
Noted (AI summary) The CQC states that the location where the death occurred was not registered with them and appears to fall outside the scope of registration and regulation by them. They have requested interested person status and an extension to gather further information. The CQC states that the sheltered accommodation where the deceased resided is not registered with them and therefore not regulated by them, so they cannot comment on the specific concern raised.
Claire Twinn
All Responded
2023-0386 16 Oct 2023 East London
Bart Health NHS Foundation Trust Department of Health and Social Care
Concerns summary (AI 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 Planned (AI summary) The Trust developed a SOP for patients with learning disabilities in the Emergency Department, including instruction to keep them overnight with a low threshold, and highlighting issues at safety handover. They also ensure discharge letters are printed, and the LD team will audit discharge advice. A training package around communicating with vulnerable patients, including a case study of a patient with LD in the Emergency Department, has been put together and is being delivered at induction and consultant meetings. The Trust is procuring specialist equipment, and has increased reporting radiologists and radiographers. The Department is aware of Barts Health NHS Trust's response and highlights the Down Syndrome Act 2022 and related guidance which is currently being developed following a call for evidence and engagement with lived experience and will be issued for consultation as soon as possible this year. They also mention the Discharge Fund and care transfer hubs to support timely discharge from hospital.
Iain Farrell
All Responded
2023-0407 13 Oct 2023 Dorset
National Coasteering Charter
Concerns summary (AI 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 Planned (AI summary) The NCC will update its 'Safety Advice for Coasteering Providers 2015 Version 3' to address the coroner's concerns. They will consult with members starting January 2024, produce an updated version by March 1st 2024, provide updates to members ahead of the 2024 season, and add key learning points to the NCC Guide Award. The NCC will update its 'Safety Advice for Coasteering Providers 2015 Version 3' to address the coroner's concerns. They will consult with members starting January 2024, produce an updated version by March 1st 2024, provide updates to members ahead of the 2024 season, and add key learning points to the NCC Guide Award.
Alex Dews
All Responded
2023-0380 10 Oct 2023 South Yorkshire (Western)
Department for Education Department of Health and Social Care
Concerns summary (AI 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.
Noted (AI summary) Outwood Grange Academies Trust details the mental health and wellbeing services involved with the academy, referral processes, and discharge procedures. They note that further guidance from the DfE on support in schools for pupils who are transgendering is still awaited. The DfE is working with the Minister for Women and Equalities to develop guidance to support schools and colleges in relation to children who are questioning their gender, with a public consultation planned before publication. The Department of Health and Social Care outlines NHS England's plans to increase access to community mental health services for children and young people, and to implement new access and waiting time standards. They also describe NHS England's overhaul of children’s gender identity services following recommendations from Dr. Cass.
Kirandip Bharaj
All Responded
2023-0379 9 Oct 2023 Blackpool & Fylde
Blackpool Council
Concerns summary (AI summary) The coroner notes that adult social care staff may lack the tools, training, and guidance to recognise and address eating disorders in vulnerable people, potentially leading to delays in necessary medical assessment and treatment.
Action Planned (AI summary) Blackpool Council is undertaking an internal review of the circumstances and will share the learning across services. They have a plan including AMHP supervision, exploring risk assessments and approaching LSCFT Eating Disorder service for an awareness session for all AMHPs early in 2024.
Sandra Curran
All Responded
2023-0378 9 Oct 2023 Manchester South
ABTA – The Travel Association Foreign, Commonwealth and Development O…
Concerns summary (AI 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.
Noted (AI summary) ABTA acknowledges the coroner's concerns and outlines its role in providing guidance to travel industry members and consumers, particularly regarding health and safety. They highlight their work with the FCDO and their consumer safety information, but state they are not aware of the full facts in the specific case. The FCDO has enhanced its Travel Advice on swimming safety to include a link to the Royal Life Saving Society’s (RLSS) “Water Safety on Holiday” page in the “Swimming safety” section of the “Safety and Security” page.
Kellie Poole
All Responded
2023-0364 4 Oct 2023 Derby and Derbyshire
Health and Safety Executive
Concerns summary (AI 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.
Noted (AI summary) The HSE acknowledges the concerns regarding cold water immersion activities, stating that existing regulations and guidance from other organisations (RNLI, National Water Safety Forum) provide a suitable basis for businesses to operate safely. They will not be publishing specific guidance at this time but will keep the activity under review and raise awareness among local authority enforcement officers.
Marcel Wochna
All Responded
2023-0332 14 Sep 2023 Hampshire, Portsmouth and Southampton
Hampshire & Isle of Wight Constubulary
Concerns summary (AI 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 Planned (AI summary) Hampshire and Isle of Wight Constabulary is rectifying an absence of Cold Water Shock information in the E-Learning Training package, and an updated 'Working Near Water Procedure' will be made available to officers and staff by the end of November 2023. Hampshire and Isle of Wight Constabulary is rectifying an absence of Cold Water Shock information in the E-Learning Training package, and an updated 'Working Near Water Procedure' will be made available to officers and staff by the end of November 2023.