Suicide

PFD Category
Reports: 847 Areas: 72 Earliest: Feb 2015 Latest: 7 Apr 2026

85% response rate (above 63% average). 43% of classified responses show concrete action taken. Reports rose 26% from 117 (2023) to 148 (2024).

Response Status
Responded 719 No Response 10 Historic 113 Pending 1
AI Classification
Action Taken 43%
Action Planned 37%
Noted 19%
Disputed 1%
Based on 1,133 classified responses
Reports by Quarter
PFD Reports
847 results
Coroner name:
Response Pending
2026-018 Category:This report is being sent to:
Cleveland Police REGULATION 28 REPORT TO PREVENT DEATHST…
Concerns summary (AI summary) The police search for a missing person was hampered by inaccurate recording of location and search outcomes, and a failure to act on heat source information, contributing to an unorganised and uncoordinated search. The family were incorrectly told that no heat sources had been identified.
Action Taken (AI summary) • Staff were reminded to undertake a risk assessment when undertaking medication reviews. • Risk assessment is a continuous process in which clinicians are required to assess an individual's risks and any changes thereto on an ongoing basis. • Should any changes in risk be identified during a review, these must be clearly documented within the electronic care records and within the patient's risk assessment.
Matilda Davis
Response Pending
2026-0198 7 Apr 2026 Warwickshire
Warwickshire County Council – Children … Warwickshire County Council – Children …
Concerns summary (AI summary) Suicide prevention training is not mandatory for frontline practitioners within Warwickshire Children’s Services, potentially leading to variability in practice when responding to indications of self-harm or suicidal thoughts.
Melanie Pinnell
All Responded
2026-0185 26 Mar 2026 Suffolk
Unity Healthcare
Concerns summary (AI summary) No follow-up was offered to the deceased by the GP practice after she described suicidal ideation and suicidal thoughts; a Consultant Psychiatrist's request for Sertraline was not actioned by a GP, posing a risk to patient safety.
Action Taken (AI summary) • Following this incident, Unity Healthcare commissioned a comprehensive Patient Safety Incident Investigation (PSII) in accordance with the NHS Patient Safety Incident Response Framework (PSIRF). • The investigation utilised system-based analytical tools, including the Systems Engineering Initiative for Patient Safety (SEIPS) and the Yorkshire Contributory Factors Framework.
Robert Day
No Identified Response
2026-0169 24 Mar 2026 Kent and Medway
Department for Women’s Health and Metal… Department of Health and Social Care Home Office
Concerns summary (AI summary) Frontline emergency services lack national guidance for managing complex, time-critical mental health crises where existing legal powers may be insufficient or unclear, risking patient lives.
Delwyn Preece
All Responded
2026-0165 17 Mar 2026 South Yorkshire East
Rotherham Doncaster South Humber NHS Fo…
Concerns summary (AI summary) Ward leave was granted without mental state exams or risk assessments, and medical records suffered from poor detail and unacknowledged retrospective entries, hindering effective investigation.
Action Taken (AI summary) • The Trust’s patient leave policy (including Section 17 leave for detained patients, and also applicable to informal patients) has been revised to clarify and strengthen documentation requirements around leave. • Before any patient goes on leave, a thorough pre-leave mental state and risk assessment must be conducted and documented. • Upon the patient’s first return from leave, staff must record a timely review of the patient’s condition and any issues arising from the leave.
Natalie Ainsworth
All Responded
2026-0162 17 Mar 2026 County Durham and Darlington
Durham Police
Concerns summary (AI summary) Critical information about a vulnerable missing person's suicide threat was not passed to officers, resulting in an inaccurate police risk assessment and inappropriate response to her mental health history.
Action Taken (AI summary) • The Force has reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation. • Changes have been made to how that information is recorded and shared with those engaged in enquiries to locate the missing person and to ensure that all information is readily available to those conducting reviews of risk assessments. • The Constabulary had already reviewed it’s Missing From Home Policy and Guidance and provided updated training to those conducting risk assessments.
Tania Jarman
No Identified Response
2026-0143 12 Mar 2026 Cheshire
Department of Health and Social Care
Concerns summary (AI summary) Persistent shortage of mental health beds risks lives, and clinicians may apply an artificially high threshold for admission due to system pressures.
Taylor Maddox
All Responded
2026-0136 9 Mar 2026 Devon, Plymouth and Torbay
North Devon Council
Concerns summary (AI summary) Psychiatric patients discharged from hospital face inadequate housing support due to poor communication with housing services and assessment processes that do not sufficiently account for mental health vulnerabilities.
1 response from North Devon District Council
Joanna Hillard
All Responded
2026-0128 5 Mar 2026 Somerset
Department of Health and Social Care
Concerns summary (AI summary) The Mental Capacity Act 2005 and current understanding fail to adequately recognise how controlling and coercive behaviour can impair a person's decision-making ability.
1 response from Department of Health and Social Care
Mark Hughes
All Responded
2026-0123 4 Mar 2026 Manchester South
Greater Manchester Mental Health NHS Fo…
Concerns summary (AI summary) Systemic delays in urgent mental health referrals to Home Based Treatment Teams, combined with the inability of general practice professionals to make direct referrals for high-risk patients, created dangerous gaps, particularly over weekends.
Action Taken (AI summary) • The Trust carried out a review of care and treatment and identified learning with an action to explore whether a PCN can refer directly to HBTT. • Mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust.
Mujahid Adam
Partially Responded
2026-0125 3 Mar 2026 Inner North London
HMP Pentonville HMPPS Ministry for Justice
Concerns summary (AI summary) Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.
Action Planned (AI summary) • HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. • The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention measures to officers, including what constitutes an observation and how to perform one. • All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process.
Benjamin Websdale
All Responded
2026-0094 17 Feb 2026 West Sussex, Brighton and Hove
National Police Chiefs Council
Concerns summary (AI summary) There's no national recording of police officer suicides during misconduct investigations, preventing identification of risk and support needs. Also, not all police forces have implemented trauma education campaigns.
Action Taken (AI summary) • The NPCC has been collating near real time suspected suicide surveillance data since January 2022, facilitated through the NPCC Suicide Prevention Steering Group and formulated from data returns provided by police forces in England, Scotland, and Wales. • Data returns are voluntary and used for Police Officer and Police Staff deaths by suspected suicide over recent years. • The NPCC is working with the College of Policing to develop a national curriculum for trauma awareness training for police officers.
David Thompson
All Responded
2026-0080 10 Feb 2026 Devon, Plymouth & Torbay
Devon & Cornwall Police
Concerns summary (AI summary) Police widely use the term 'suicidal ideation' which is not understood by the public or consistently by officers, risking critical information being missed in missing person reports.
Action Planned (AI summary) • Devon & Cornwall Constabulary acknowledges the concerns raised regarding the use and understanding of the term ‘suicidal ideation’ within operational decision- making and communications with members of the public. • As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents. • Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking abou
Gareth Chumber-Kelly
Partially Responded
2026-0073 9 Feb 2026 North London
HMP Pentonville HMPPS Ministry for Justice +1 more
Concerns summary (AI summary) Inefficient prison reception processes lead to lost critical prisoner information, and suicide/self-harm training for staff was suspended despite high rates of suicidal ideation and ligature deaths.
Noted (AI summary) • HMP Pentonville has introduced a digital induction passport to consolidate key risk information from paper records into a secure electronic format. • The prison has appointed a Head of Early Days with specific responsibility for the reception function, who is leading a comprehensive review of reception procedures. • The group safety team conducts regular early days exercises, which replicate a prisoner’s arrival and induction experience.
Mansoor Zaman
All Responded
2026-0072 6 Feb 2026 East London
Department of Health and Social Care East London Foundation NHS Trust
Concerns summary (AI summary) Nursing staff failed to instigate MHA authorisations, adequately document care, reappraise risk after violent behaviour and absconding, and promptly report a missing patient to the police via emergency channels.
3 responses from Department for Health and Social Care, East London NHS foundation Trust addendum, East London NHS Foundation Trust
Paul Thompson
All Responded
2026-0066 6 Feb 2026 Suffolk
HM Prison, Probation and reducing offen…
Concerns summary (AI summary) HMP Norwich had inadequate arrangements for releasing prisoners needing mental health care, leading to failures in ensuring follow-up and timely information sharing with Probation Services.
1 response from HMP Norwich
Kallum Reed
All Responded
2026-0061 5 Feb 2026 West London
Department of Health and Social Care West London NHS Trust
Concerns summary (AI summary) Unacceptably long waits for ASD/ADHD services and mental health crisis team gate-keeping failures led to patients being denied crucial in-person assessments and ongoing close care.
Noted (AI summary) • The Trust is the provider for adult ASD assessments in Ealing. • When this service was established in 2021, it was modelled upon historical trends in activity referred to providers outside North West London, and commissioned and resourced by North West London ICB to complete 86 assessments per year. • In the last three full financial years against this target, we delivered 547 assessments (212%), however demand continued to grow leading to a considerable backlog of patients awaiting diagnostic assessment experiencing unacceptable delays.
Ellame Ford-Dunn Prevention of future deaths report
All Responded
2026-0056 3 Feb 2026 West Sussex, Brighton and Hove
NHS England & NHS Improvement
Concerns summary (AI summary) Insufficient Tier 4 Paediatric Mental Health beds lead to long waits, resulting in children with mental health needs being inappropriately held on acute paediatric wards unsuitable for their care.
Action Taken (AI summary) NHS England has provided £180,000 to University Hospitals Sussex NHS Foundation Trust to support the recruitment of additional mental health nurses. A new tri-funded short-term residential alternative to hospital admission is expected to open in 2026 to support young people in crisis.
Simon Moss
All Responded
2026-0052 1 Feb 2026 Inner South London
[REDACTED] Chief Executive Officer (CEO…
Concerns summary (AI summary) Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.
Action Planned (AI summary) • NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings through the Culture of Care national programme. • NHS England launched Staying safe from suicide guidance in June 2025 to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts.
Nigel Feckey
All Responded
2026-0047 28 Jan 2026 Leicester City and South Leicestershire
Ministry of Justice
Concerns summary (AI summary) The 'Offence Neutrality' policy in prisons, mingling sex offenders with mainstream prisoners, fostered fear, bullying, and self-harm among vulnerable inmates, posing a risk of future deaths where still implemented.
Action Taken (AI summary) • HMPPS provides evidence-based guidance for governors and directors to support them to make safe and appropriate decisions on accommodation arrangements for people convicted of sexual offences (PCOSOs). • The guidance sets out that governors and directors have discretion over whether PCOSOs should be integrated or separated, and that consideration should be given to the specifics and facilities of each establishment.
Lucy Thornton
All Responded
2026-0040 27 Jan 2026 Hampshire, Portsmouth Southampton
Isle of Wight NHS Trust
Concerns summary (AI summary) Ambulance call handler training was inadequate regarding Category 1 response criteria for hanging incidents, and procedures for obtaining further information from callers were not followed.
Action Taken (AI summary) The Isle of Wight NHS Trust has addressed the call handler's actions and amended guidance to clarify the need for direct contact with individuals at risk, regardless of location. A comprehensive training programme for call handlers on risk assessment and categorisation for suicidal patients is being delivered from February to April 2026.
Tamara Logan
All Responded
2026-0035 22 Jan 2026 Manchester
Department for Work and Pensions
Concerns summary (AI summary) An incorrect benefits assessment, uncorrected by review, significantly impacted the deceased. Additionally, standard letters were sent despite recognised vulnerabilities, without attempting to reduce associated risks.
Action Taken (AI summary) • The department accepts that its initial decision to reduce Ms Logan’s benefits may have been unjustified. • The department investigated the decision and is taking steps to minimise such decisions in the future. • The department shares the coroner's concern that its decision may have influenced Ms Logan.
Linda Fury
All Responded
2026-0029Deceased 20 Jan 2026 Manchester South
Pennine Care NHS Foundation Trust
Concerns summary (AI summary) The Trust's investigation into Linda's discharge was insufficient, failing to adequately analyze the lack of local beds, decision-making process, and capacity assessment. Current ward rounds also prevent private disclosure of family concerns regarding risk.
Action Taken (AI summary) The Trust has made Carer Awareness Training mandatory for all frontline staff and implemented strengthened MDT documentation, patient and carer submission forms, enhanced ward-round communication pathways, and improvements to PARIS functionality to improve carer engagement and reduce risks.
Martin Bryant
All Responded
2026-0030 19 Jan 2026 Essex
Essex University Partnership Trust NHS England
Concerns summary (AI summary) Mental health crisis patients face dangerously long waits in open reception areas due to a severe lack of local and national mental health beds, and inadequate facilities for appropriate waiting.
Action Taken (AI summary) NHS England is rolling out dedicated 24/7 neighbourhood mental health centres and specialist Mental Health Emergency Departments, and has reinforced patient flow improvement as a key priority in its 2025/26 operational planning guidance, with plans to reduce Out of Area Placements. EPUT has changed management processes to include risk assessments for patients waiting in reception, secured capital funding for Mental Health Urgent Care Department (MHUCD) refurbishment with approved plans for dedicated spaces, and implemented a Therapeutic Acute Inpatient Operating Model.
Wayne Walton
All Responded
2026-0028 16 Jan 2026 Coventry
Mental Health Directorate
Concerns summary (AI summary) Inpatient staff lacked awareness of Home Treatment Team policies, leading to inadequate risk assessments and safety plans. There is also no guidance for managing potential conflicts of interest when staff recognise patients outside of personal relationships.
Action Taken (AI summary) The Trust updated its patient transfer and discharge policy in February 2026 with clear guidance for inpatient teams on documentation for Home Treatment Team (HTT) discharges, implemented an 'end of shift' handover form, and developed scenario guidance for staff on professional boundaries while a new policy is being developed.