Product related deaths
PFD Category
Reports: 131
Areas: 54
Earliest: Oct 2013
Latest: 5 Aug 2025
77% response rate (above 63% average). 31% of classified responses show concrete action taken. Reports rose 150% from 6 (2023) to 15 (2024).
PFD Reports
81 resultsMichael Woods
All Responded
2021-0015
18 Jan 2021
County of Dorset
National Rifle Association and National…
Concerns summary (AI summary)
Shooting range staff lack consistent national training in identifying abnormal behaviour or conducting emergency response exercises, which could significantly improve safety protocols for participants.
Action Planned
(AI summary)
The NRA and NSRA will develop training for staff at their ranges on identifying and responding to potential self-harm, to be delivered by September 2021. They will review their emergency response procedures, testing them twice yearly, and will publish guidance for other rifle ranges by October 2021.
Ruben Bousquet
All Responded
2020-0298
18 Dec 2020
London Inner South
Department of Health and Social Care
Food Standards Agency
Ministry of Housing, Communities and Lo…
Concerns summary (AI summary)
Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.
Action Planned
(AI summary)
The MHRA sought advice from the UK Commission on Human Medicines (CHM) on a range of areas to support the effective and safe use of AAIs. The AAI EWG recommended a number of other measures including reinforcement of the need for all patients at risk of anaphylaxis to carry two AAIs at all times. The FSA is undertaking consumer research to gather information and insights from people with food allergies and is considering the benefits of developing a food allergy safety scheme for allergen management within food businesses. They are supporting businesses to prepare for new allergen labelling rules coming into effect on 1st October 2021. The FSA is establishing a way for people to directly report information regarding anaphylactic reactions caused by food allergies that do not result in death. The MHRA is considering making AAI devices more widely available for use in exceptional, emergency situations.
Lee Elliott
All Responded
2020-0265
26 Nov 2020
County of Cumbria
Department of Health and Social Care
Concerns summary (AI summary)
Toxic substances are easily and cheaply obtainable online without safeguards, and are advocated on websites as a method for suicide, leading to multiple deaths.
Noted
(AI summary)
The Department acknowledges concerns about the availability of suicide methods online and outlines actions to reduce suicide rates through the Suicide Prevention Strategy for England, including reducing access to the means of suicide and working with online retailers of harmful substances.
Jean Williams
All Responded
2020-0239
16 Nov 2020
Manchester (West)
NHS England, Blackpool Teaching Hospita…
Concerns summary (AI summary)
Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.
Action Taken
(AI summary)
Blackpool Teaching Hospitals addressed concerns about bed lever fitting at Thornton House by clarifying that Occupational Therapists, now correctly trained, will prescribe and fit them after a full assessment. The intermediate care team and LCC were informed of updated processes at a meeting on December 2, 2020, and the Trust shared findings with senior Allied Health Professionals across the Lancashire and South Cumbria Integrated Care System. Lancashire County Council updated their 'Bed Rail and Bed Lever Policy and Procedure' to clarify the escalation process for concerns, effective January 8, 2021, with a further review planned for April 2021. They also rectified a miscommunication regarding bed lever usage at Thornton House, agreeing with Blackpool Teaching Hospitals that bed levers can be used when appropriate and fitted only by trained Occupational Therapy staff. Mobility 2000 Ltd has carried out further training with staff on fitting bed levers and straps, and will now supply a hard copy of the manufacturer's instructions with every bed lever.
Pauline Oakley
All Responded
2020-0304
18 Sep 2020
Inner North London
East End Homes, East London NHS Foundat…
Concerns summary (AI summary)
There was no safety assessment of the patient's flat or appliances upon hospital discharge. Additionally, the fire alarm system was unmonitored, relying on residents who may have assumed it was.
Noted
(AI summary)
East London NHS Foundation Trust clarifies that responsibility for environmental risk assessments following the patient's discharge from hospital would lie with the Reablement Team, which falls within the remit of the London Borough of Tower Hamlets. However, they will discuss the case within their regular team meetings. East End Homes states that the smoke alarms were of an appropriate standard, properly installed, maintained, and operated when activated. They believe that residents do not expect domestic alarms to be monitored externally, and they offer general guidance on fire safety. The GP practice will ensure the multi-disciplinary team and Social Services are made aware of concerns raised about the adequacy or safety of a patient's home environment. Clinicians can prompt the Care Navigator or Social Worker at the monthly Integrated Care Multidisciplinary Meeting to ensure that appropriate fire safety checks are implemented.
Brenda Elmer
All Responded
2020-0159
14 Aug 2020
West Sussex
NHS England
Public Health England
Concerns summary (AI summary)
Discharged patients were not effectively informed about a hospital-acquired Listeria outbreak, delaying diagnosis. Additionally, there are no legal requirements for private labs or hospitals to share Listeria isolates, hindering timely outbreak identification.
Action Taken
(AI summary)
PHE implemented an Incident Management Team following listeria cases, inspected the sandwich manufacturer, and wrote to national microbiological standards to update the SOP for identification of Listeria. The updated SOP advises hospital laboratories to refer all isolates from patients to PHE.
Janet Jasper
All Responded
2020-0014
17 Jan 2020
Rutland and North Leicestershire
Cadent Gas Ltd
Gas Safe Network
Institution of Gas Engineers
+2 more
Concerns summary (AI summary)
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an incident.
Action Planned
(AI summary)
Following a review, Gas Distribution Networks (GDNs) have agreed on a revised EM72 policy for responding to gas leak callouts, particularly "no trace" declarations. HSE also undertook communication with residents and gas engineers in the local area, including hosting a residents meeting and providing leaflets to explain potential risks and actions. Gas Distribution Networks (GDNs) clarified procedures for checking adjoining properties during internal gas escape investigations, focusing on external sources. The GDNs will brief operational teams on the revised requirements, expected to be in place across all networks by mid-summer 2020.
Shneur Kaye
All Responded
2020-0013
17 Jan 2020
Manchester (North)
Bury Council
Concerns summary (AI summary)
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
Action Taken
(AI summary)
North Manchester Care Organisation outlines changes implemented after the incident, including revised discharge processes for children presenting to A&E with overdoses, new referral pathways for children with mental health needs, and mandatory safeguarding training for staff. Bury Council conducted a service review of the Multi Agency Safeguarding Hub (MASH) in early 2022, reinforcing strength-based practices and parental involvement unless safeguarding or legal reasons prevent it. The MASH also consults with referrers to clarify information and consider alternative support pathways.
Owen Carey
All Responded
2019-0335
30 Sep 2019
London Inner (South)
British Society for Allergy and Clinica…
Byron Hamburgers
Department of Environment, Food and Rur…
+3 more
Concerns summary (AI summary)
The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to clearly state key allergen information, creating false reassurance for customers.
Noted
(AI summary)
Byron has rectified the lack of records kept of on-job training immediately and each employee will now have records kept, and are investing in a market leading training system called "Flow" which is launched in the business from November where every employee will have their own personal training modules and records. BSACI will write to the chair of the FSA to advocate for funding for the UK Fatal Anaphylaxis Registry (UKFAR), which they are exploring closer working with to ensure its sustainability. National Trading Standards states that food safety and allergen regulation is outside their remit, which focuses on regional or national issues like complex consumer fraud. They note the Food Standards Agency is responsible for allergen legislation and policy. The FSA plans to develop an online reporting system and improve data sharing for allergic reactions, including those not resulting in death, to enable timely identification of trends and action by local authorities. DHSC will work to increase information prevalence on anaphylactic deaths and will support the FSA's reporting platform.
Savannah-Rose Owen
All Responded
2018-0367
22 Nov 2018
Manchester (South)
Department for Business
Department of Health and Social Care
Concerns summary (AI summary)
Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.
Noted
(AI summary)
The Department has passed concerns about a nursing pillow lacking proper safety warnings to the Office for Product Safety and Standards (OPSS) for investigation and potential action with Local Authority Trading Standards. The Department clarifies that nursing pillows aren't medical devices and directs safety regulation concerns to the Department for Business, Energy and Industrial Strategy. They highlight existing guidance and resources from health visitors, midwives, Public Health England, the Lullaby Trust, Start4Life, and NHS Choices regarding safe sleeping and SIDS prevention.
Douglas McTavish
All Responded
2017-0311
31 Oct 2017
North Wales (East & Central)
Whirlpool (UK) Appliances
Concerns summary (AI summary)
Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the company may be too reluctant to rely on 'soft data' such as reported fires. Additionally, public awareness of the risk of spontaneous combustion may be insufficient.
Action Taken
(AI summary)
Whirlpool will support initiatives to raise consumer awareness of risks such as spontaneous combustion and has added relevant usage instructions to the 'Register my appliance' website.
Bernard Hender
All Responded
2017-0311-wp25922
31 Oct 2017
North Wales (East & Central)
Whirlpool (UK) Appliances
Concerns summary (AI summary)
Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.
1 response
from Whirlpool UK Appliances Limited
Brian Betterton
All Responded
2017-0224
11 Sep 2017
Bedfordshire and Luton
Department for Business, Energy and Ind…
Concerns summary (AI summary)
Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Action Taken
(AI summary)
The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires in white goods on 19 July. They have also supported the development of a new BSI code of practice on corrective action and recalls and commissioned research to understand how to increase the impact and effectiveness of product safety messages.
Isabella Pritchard
All Responded
2017-0261
16 Aug 2017
Berkshire
Department of Business, Energy and Indu…
Department of Communities and Local Gov…
Concerns summary (AI summary)
The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation significantly increases the risk of serious incidents.
Action Planned
(AI summary)
The department will ask the Building Regulations Advisory Committee to reconsider regulating stone fire surrounds and will alert registered installers to good practice guidance. Officials will also continue working with other agencies to keep guidance up to date.
Linda Baranowski
All Responded
2017-0341
22 Jul 2017
Hertfordshire
Hertfordshire Trading Standards
National Food Crime Unit, Food Standard…
Concerns summary (AI summary)
Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products with unknown effects.
Action Planned
(AI summary)
The FSA Incidents Team investigated Mrs. Baranowski's case and the National Food Crime Unit has been actively working against the sale of dangerous food, including DNP, promoting awareness campaigns and monitoring the internet for sales. Hertfordshire Trading Standards will liaise with national government agencies and regulators regarding food product safety, offering input into developing a national strategy if requested by the Food Standards Agency.
Maurice Macdonnell
All Responded
2017-0188
14 Jun 2017
London Inner (South)
Medicines and Healthcare products Regul…
Concerns summary (AI summary)
A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.
Noted
(AI summary)
The MHRA reviewed the SUSAR report and determined that the symptoms were in line with the known safety profile for nivolumab, and no further action is required for participants in nivolumab clinical trials. They also stated that conflict of interest lies outside the remit of MHRA for clinical trials.
Howard Jeffers
All Responded
2017-0115
15 May 2017
London (North)
Pharmaceutical Chemistry, Drug Misuse a…
Concerns summary (AI summary)
The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.
Noted
(AI summary)
Imperial College London's Toxicology Unit acknowledges the difficulties in accurately analyzing and detecting NPSs due to their changing nature, lack of standards and pharmacological data, and states that no action is proposed. Alere Forensics describes its ongoing efforts to improve the analysis and detection of new psychoactive substances (NPS), including developing novel screening techniques, working with universities to obtain reference materials, and providing training to stakeholders. The Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit at the University of Hertfordshire is engaged in research to identify NPS and provide updated clinical guidelines, including using computational models to identify potential compounds before they appear on the market.
Grace Roseman
All Responded
2016-0455
19 Dec 2016
West Sussex
Bednest Ltd
Department for Business, Energy and Ind…
Concerns summary (AI summary)
Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation with unaware customers.
Action Planned
(AI summary)
The Department for Business Energy and Industrial Strategy will discuss with BSI how to ensure paediatric advice is fed into the revision of the standard for cribs and cradles and will engage with stakeholders to gather further intelligence on products such as these. They will also engage with RoSPA on whether there is a need to improve general guidance and raise consumer awareness surrounding the sleep environment. Bednest has modified its cribs, sent modification kits to known purchasers, added additional labeling, ceased sales through retailers like NCT, and maintains information about the modification kit on their website. They continue to monitor second-hand sales and work with Trading Standards.
Roy Lawton
All Responded
2016-0441
9 Dec 2016
Staffordshire (South)
Marks and Spencer
Concerns summary (AI summary)
The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.
Noted
(AI summary)
M&S expresses condolences and states that the Gown was compliant with all legal requirements. M&S goes significantly beyond the legal requirements in its flammability testing of adult dressing gowns.
Samantha Hopkins
All Responded
2016-0316
6 Sep 2016
Portsmouth and South East Hampshire
South Central Ambulance Service
Warwick Medical School
Concerns summary (AI summary)
Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Action Planned
(AI summary)
New labels detailing exclusion categories will be placed on further issues of the trial drug packs. SCAS has committed that by January 2017 that all trial drugs in circulation will have the new labels affixed to the trial drugs bag or external bag. The University has instructed participating Ambulance Services to issue a reminder to all participating staff, to reiterate the inclusion and exclusion criteria for the trial. Compliance with this instruction shall be specifically audited during annual Quality Assurance Site visits.
Nadine Brookes-Walker
All Responded
2015-0463
16 Nov 2015
Manchester (North)
Teva UK Ltd
Concerns summary (AI summary)
Packaging for Fentanyl patches may not adequately convey the severe risks associated with using damaged patches, potentially leading to patient misuse.
Noted
(AI summary)
Takeda believes the existing patient information leaflet adequately addresses the issue of damaged patches, and they have requested a review to determine if changes are needed; the MHRA also reviewed product information for fentanyl patches in April 2015.
Irene Hamilton-Parker
All Responded
2015-0197
20 May 2015
Staffordshire (South)
Department of Business Innovation and S…
Concerns summary (AI summary)
Clothing made of easily flammable man-made fabrics poses a risk, and steps should be considered to reduce the flammability of manufactured or imported clothing.
Noted
(AI summary)
The Department for Business Innovation and Skills acknowledges concerns about clothing flammability but states that most clothing is flammable and reducing it would require flame retardants with their own risks. They don't believe there's sufficient evidence to extend flammability requirements to other types of clothing but will keep the issue under review.
Jason Houghton
All Responded
2015-0127
30 Mar 2015
Manchester (West)
Home Office
Concerns summary (AI summary)
The unregulated online supply and international importation of Class A drugs, specifically Diacetyl Morphine/Heroin in pill form via postal systems, poses a significant risk of future deaths.
Action Taken
(AI summary)
The Home Office acknowledges concerns about online drug supply, notes ongoing efforts by law enforcement to close UK-based websites and work with international partners. Since the death, the MHRA closed down the website Wmedipk com.
Joseph Allison
All Responded
2015-0103
23 Mar 2015
London (East)
British Healthcare Trades Association
Handicare Accessibility Ltd
Concerns summary (AI summary)
Service engineers lack specific training on a known stairlift defect and safety checks. Furthermore, no national safety recall or industry-wide advisory has been issued for the defective Minivator 2000 stairlift.
Action Planned
(AI summary)
Handicare has adjusted internal processes and training for in-house engineers. It will also raise the issue of sharing safety information with all manufacturers at the next BHTA stairlift section meeting and via letter during the week commencing 15th June 2015. BHTA will remind manufacturer members to continue training to address field safety issues until all products have been traced and necessary action taken. BHTA will recommend that the Health & Safety Executive talk to the MHRA and see if they might tap into the alerting system for alerts regarding products sold into the care sector.
Brenda Leyland
All Responded
2015-0112
20 Mar 2015
Leicester (City & South)
Department of Health and Social Care
Concerns summary (AI summary)
Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.
Noted
(AI summary)
The Department of Health acknowledges the concerns raised about helium gas and suicide, noting ongoing discussions with partners but without specific outcomes to report. They highlight the need to balance helium availability with safety and reference Samaritans' media guidelines.