Suicide

PFD Category
Reports: 841 Areas: 72 Earliest: Feb 2015 Latest: 12 Mar 2026

82% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 26% from 117 (2023) to 148 (2024).

Response Status
Responded 693 No Response 15 Historic 112 Pending 15
AI Classification
Action Taken 55%
Action Planned 23%
Noted 14%
Disputed 8%
Based on 570 classified responses
Reports by Quarter
PFD Reports
841 results
Scott Rider
All Responded
2024-0210 12 Apr 2024 Milton Keynes
HM Prison and Probation Services
Concerns summary The indefinite nature of IPP sentences traps prisoners, leading to feelings of hopelessness and challenging behaviours, raising concerns about inhumane treatment and future deaths if not reviewed.
Action taken summary HMPPS is pursuing legislative reform through the Victims and Prisoners Bill to reduce the qualifying period for IPP licence termination from 10 to 3 years, with a presumption of termination and automa
Paul Dow
All Responded
2024-0192 10 Apr 2024 Manchester North
North West Ambulance Service NHS Trust Department of Health and Social Care
Concerns summary Emergency calls for a clear overdose and suicide attempt were inappropriately low-coded, lacked clinician involvement, and were not escalated despite the patient becoming unresponsive.
Action taken summary North West Ambulance Service has implemented a new process for overdose/poisoning calls, routing Category 3 calls to a Specialist Practitioner for further triage within 30 minutes, with escalation to
Paul Templeton
All Responded
2024-0188 5 Apr 2024 Suffolk
Norfolk and Suffolk NHS Foundation Trust
Concerns summary The Trust seriously failed to recognize a patient's prolonged refusal to eat or drink as an active suicide attempt and an elevated suicide risk, indicating a systemic failure in risk assessment.
Action taken summary Norfolk and Suffolk NHS Foundation Trust has held a reflective Multi-Disciplinary Team Away Day for Willows ward staff, including case studies on food and drink refusal to enhance clinical risk assess
Sarah Adams
All Responded
2024-0170 28 Mar 2024 Berkshire
Reading Borough Council Adult Social Ca… Berkshire Healthcare NHS Foundation Tru… Cygnet Hospital
Concerns summary Clinicians and practitioners involved in mental health inpatient discharge lack adequate training in the discharge process, particularly concerning complex issues arising from out-of-area admissions.
Action taken summary Cygnet Healthcare has provided 4.5-hour face-to-face training on care planning, risk assessment, and discharge processes to all multi-disciplinary team members at Cygnet Harrow, with annual refreshers
Ellen Woolnough
All Responded
2024-0184 28 Mar 2024 Suffolk
Norfolk and Suffolk NHS Foundation Trust NHS England
Concerns summary Concerns persist regarding inadequate mental health discharge decisions, insufficient crisis team risk assessments, and downgrading of urgent referrals, with many identified safety measures remaining prospective or unimplemented by the Trust.
Action taken summary NHS England largely defers the concerns to Norfolk and Suffolk NHS Foundation Trust, noting the Trust's planned actions including a Quality Improvement Programme and new Crisis Rehabilitation Home Tre
Daniela Pani
Partially Responded
2024-0664 28 Mar 2024 Berkshire
Berkshire Healthcare NHS Foundation Tru… South Western Railways British Transport Police
Concerns summary Unimplemented safety measures at a train station, including lack of Samaritan signs and low fencing, were identified. Additionally, mental health staff lacked training on managing service users who decline critical 72-hour review meetings.
Action taken summary South Western Railways states that Samaritan signs are conspicuously placed at Bracknell station, and 'Managing Suicide Contact' training is now mandatory for all new employees and front-facing third-
Jacqueline Cobain
All Responded
2024-0163 25 Mar 2024 London Inner (South)
South London and Maudsley NHS Foundatio…
Concerns summary A system flaw allowed a patient to submit concerning questionnaire responses after cancelling an appointment, but there was no protocol to alert clinicians to review these urgent responses outside the standard timeframe.
Action taken summary South London and Maudsley NHS Foundation Trust explicitly states they will not implement a new protocol to automatically follow up on cancelled appointments with concerning questionnaire responses. Th
Alexander Lyalushko
All Responded
2024-0449 25 Mar 2024 Nottingham and Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary The initial serious incident review following death was inadequate, failing to identify crucial missed GP actions, mislabel improvements, and exclude family input, indicating a lack of thorough investigation and learning.
Action taken summary Nottinghamshire Healthcare NHS Foundation Trust has accepted the coroner's findings and is undertaking a further review and addendum to the incident report, which is nearing completion, to incorporate
Mary Jones
All Responded
2024-0159 21 Mar 2024 Cheshire
Amazon UK
Concerns summary Amazon continues to sell a "well known suicide book" which is easily accessible and quickly deliverable, despite awareness of its potential for harm and a previous coroner's intervention.
Action taken summary Amazon has reviewed the 'well known suicide book' against its content guidelines and decided not to remove it from sale, asserting its belief in freedom of expression. They highlight an existing measu
Jonathan Harris
All Responded
2024-0155 20 Mar 2024 Surrey
NHS England
Concerns summary Persistent national and local shortages of consultant psychiatrists and inpatient psychiatric beds are preventing access to essential mental health care.
Action taken summary NHS England is implementing its Long Term Workforce Plan to address psychiatrist shortages through expanded domestic training and recruitment over the next 15 years. They are also investing £1.6bn via
Sarah Sutherland
Partially Responded
2024-0148 15 Mar 2024 Surrey
Brainwaves Care Quality Commission NHS England +2 more
Concerns summary A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate with NHS mental health services.
Action taken summary NHS England highlighted significant work undertaken with private sector organisations to trial the use of Summary Care Records (SCRs) and confirmed this work will continue in 2024. It also outlined it
Tobias Mannering-Jones
All Responded
2024-0143 14 Mar 2024 Manchester South
Department for Local Government Department of Health and Social Care Greater Manchester Integrated Care
Concerns summary Long mental health waiting lists, inadequate support and unstable housing for homeless youth, especially LGBTQIA+, contribute to vulnerability and exploitation risks, compounded by poor inter-agency coordination.
Action taken summary The department plans to publish a Joint Action Plan later this year to improve mental health treatment for people using drugs and alcohol. Ministers will also write to relevant directors to clarify ex
Jason Brown
All Responded
2024-0133 12 Mar 2024 Sunderland
General Pharmaceutical Council National Pharmacy Association Lundbeck Limited +1 more
Concerns summary Dispensing full packs of medication with special container status, rather than weekly doses, poses a severe risk to suicidal patients with a history of overdose attempts.
Action taken summary The National Pharmacy Association (NPA) clarified it has no influence over special container status but will raise concerns over Zuclopenthixol dihydrochloride (Clopixol) pack size and its special con
Adrian James
All Responded
2024-0128 7 Mar 2024 Inner West London
Central and North West London NHS Found… NHS England
Concerns summary The difficulty in assessing patients with rapidly fluctuating emotional states, combined with paranoid ideation, presents significant challenges for predicting and preventing impulsive acts of self-harm.
Action taken summary NHS England stated that it is not within its remit to respond to the specific concerns regarding Adrian James's care, deferring to Central and North West London NHS Foundation Trust. It outlined gener
Nicola Rayner
All Responded
2024-0130 7 Mar 2024 Suffolk
Department of Health and Social Care
Concerns summary A severe and ongoing lack of informal Mental Health beds, both locally and nationally, directly contributed to Nicola's death and continues to pose a significant risk to other patients.
Action taken summary The Department of Health and Social Care acknowledged concerns about mental health bed capacity and referred to existing NHS Long Term Plan commitments and funding to transform mental health services
Isabella Shere
All Responded
2024-0298 5 Mar 2024 London Inner (South)
Department for Culture, Media and Sport OFCOM Department for Culture +1 more
Concerns summary Quora's platform contains easily accessible, unmoderated content related to self-harm and suicide, lacking age verification and featuring engagement functions that normalise serious subject matter for children.
Action taken summary The Department for Science, Innovation and Technology confirms the Online Safety Act (OSA) is in place to address concerns about harmful online content. The OSA will mandate tech companies to prevent
Kenneth Baylis
All Responded
2024-0117 4 Mar 2024 Nottinghamshire
Nottinghamshire Healthcare NHS Foundati…
Concerns summary The Trust failed to routinely involve family in risk and safety planning, had inadequate suicide assessments, neglected planned leave policy, and conducted insufficient incident investigations.
Action taken summary Nottinghamshire Healthcare NHS Foundation Trust has updated various policies including those for consent, information sharing, risk assessment, and planned leave. They have also amended MDT and suicid
Sandra Senior
All Responded
2024-0124 4 Mar 2024 Inner North London
Camden Council
Concerns summary Ineffective security systems and maintenance issues at a residential building, including a faulty entry door and a deceptively locked gate, allowed opportunistic access for suicide.
Action taken summary Camden Council has removed the latch and hook from the communal entrance door at Tavistock Chambers to prevent it from being held open. They have also installed an additional 'Fire Brigade' lock on th
Daniel Tucker
All Responded
2024-0115 29 Feb 2024 Nottingham City and Nottinghamshire
NHS England Department of Health and Social Care Nottinghamshire Healthcare NHS Foundati… +1 more
Concerns summary Concerns exist about a persisting culture of minimising the importance of ward-specific risk assessments and care plans. The system for allocating, recording, and ensuring effective named nurse sessions was also inadequate.
Action taken summary NHS England has issued and updated national guidance to all ambulance trusts regarding the clinical management of overdose patients. This includes requiring reviews of patients and automatic re-triage
Sylvia Crowther
All Responded
2024-0114 28 Feb 2024 Bedfordshire and Luton
Bedfordshire Police
Concerns summary Police failed to seek the victim's views on bail conditions for her husband, as required by law, and she was not informed of these conditions, missing an opportunity to consider alternative support.
Action taken summary Bedfordshire Police has provided targeted learning input to the Investigating Officer and Sergeant responsible for bail in this case, addressing the failure to follow S47ZZA PACE 1984 requirements. Th
Deborah Cooper
All Responded
2024-0199 26 Feb 2024 Wiltshire and Swindon
Amazon UK Department for Business and Trade Department for Culture +1 more
Concerns summary Books providing explicit instructions on methods for ending one's life are freely available on Amazon.co.uk. Concerns are raised about the marketing, supply, and lack of regulation for such publications.
Action taken summary Amazon reviewed the two books in question against their content guidelines but decided not to remove them, citing a commitment to freedom of expression. They noted that a banner is displayed on sensit
Matthew Price
All Responded
2024-0102 22 Feb 2024 West Yorkshire (Eastern)
Ministry of Justice
Concerns summary Concerns are raised about the welfare of individuals subject to IPP sentences, highlighting anxiety over recall and the belief that seeking mental health support could hinder their discharge process.
Action taken summary HMPPS has implemented introductory suicide prevention training for over 1700 probation staff and developed a specific briefing drawing attention to IPP sentences. They are also collaborating with othe
Mia Janin
All Responded
2024-0103 22 Feb 2024 North London
Jewish Free School
Concerns summary Concerns about ongoing gender-based bullying at the school and the lack of student confidence in current initiatives create a continued risk of future deaths.
Action taken summary The Jewish Free School has implemented a comprehensive overhaul of safeguarding practices, increased behaviour management, and delivered numerous external sessions on sexual harassment and bullying by
Samuel Curless
All Responded
2024-0089 19 Feb 2024 Manchester South
College of Policing Greater Manchester Police
Concerns summary Police training for responding to hanging casualties was inadequate and delivered mostly online, with many officers lacking necessary first aid refresher training for life-preservation.
Action taken summary The College of Policing has published a revised First Aid Learning Programme (FALP), developed through a national working group, focusing on casualty care, basic life support, and manual airway techni
Thomas Loxton
All Responded
2024-0086 15 Feb 2024 Birmingham and Solihull
Dudley Integrated Health and Care NHS T… Black Country Healthcare NHS Foundation…
Concerns summary Administrative errors caused distress to bereaved families due to unaddressed patient death notification processes between trusts, and critical safety recommendations remain outstanding or delayed.
Action taken summary Dudley Integrated Health and Care NHS Trust has immediately implemented an enhanced process for notifying patient deaths, building on existing collaborative arrangements with Black Country Healthcare.