Other related deaths

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

75% response rate (above 62% average). 38% 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 38%
Action Planned 34%
Noted 19%
Disputed 9%
Based on 164 classified responses
Reports by Quarter
PFD Reports
776 results
Claire Homer
All Responded
2023-0448 10 Nov 2023 Inner North London
Camden and Islington NHS Foundation Tru…
Concerns 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.
Owen Garnett
Historic (No Identified Response)
2023-0434 8 Nov 2023 Warwickshire
Unity MAT Health and Safety Executive
Concerns 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.
Lee Bowman
All Responded
2024-0109 8 Nov 2023 South Yorkshire East
College of Policing
Concerns 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.
Terri Harris, John-Paul Bennett, Lacey Bennett and Connie Gent
Partially Responded
2023-0467 7 Nov 2023 Derby and Derbyshire
Secretary of State for Justice Derbyshire Healthcare NHS Foundation Tr… Capita +1 more
Concerns 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.
Adam Johnson
All Responded
2023-0427 3 Nov 2023 South Yorkshire (Western)
English Ice Hockey Ice Hockey UK
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.
Musa Konteh
Historic (No Identified Response)
2023-0426 1 Nov 2023 Inner North London
Consular Feedback Team
Concerns 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
National Police Chiefs Council College of Policing
Concerns 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.
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.
Jill Brice
All Responded
2023-0401 20 Oct 2023 West Sussex, Brighton and Hove
Care Quality Commission Department for Housing
Concerns summary Care residents are not consistently reminded to keep their emergency pendants close, posing a safety risk during emergencies like fires.
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.
Claire Twinn
All Responded
2023-0386 16 Oct 2023 East London
Bart Health NHS Foundation Trust Department of Health and Social Care
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Jonathan Mann and Margaret Costa
Historic (No Identified Response)
2023-0307 24 Aug 2023 Somerset
Military Aviation Authority Civil Aviation Authority
Concerns summary Critical information about pilot capabilities, aircraft equipment, and diversion airport weather was not requested or shared, leading to poor communication and inadequate assistance for a pilot in distress.
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.
Shirley Ashelford
Partially Responded
2023-0297 17 Aug 2023 Inner South London
Bureau Veritas UK Ltd Prism Medical UK Ltd London Borough of Southwark +1 more
Concerns summary Inadequate training for hoist users and their carers on emergency procedures, coupled with inspection reports not being shared with the occupational therapy department, created significant safety gaps.
Luke Brooks
All Responded
2024-0326 17 Aug 2023 Manchester North
Communities & Local Government Department of Health and Social Care Ministry of Housing