Suicide

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

82% response rate (above 62% average). 56% 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 56%
Action Planned 23%
Noted 12%
Disputed 8%
Based on 371 classified responses
Reports by Quarter
Clear
PFD Reports
613 results
Owen Donnelly
All Responded
2025-0532 17 Oct 2025 Manchester West
Department of Health and Social Care
Concerns summary Easy online access to information for constructing weapons, currently not illegal to possess, creates a real risk due to the proliferation of unlicensed weapons while legislation is pending.
Action taken summary The Home Office confirms that the Border Security, Asylum and Immigration Bill, expected to achieve Royal Assent by December, will make it a criminal offence to import, make, adapt, supply, or offer t
Tony Duncan
All Responded
2025-0516 15 Oct 2025 City of London
South London and Maudsley NHS Foundatio…
Concerns summary A psychiatric liaison team failed to conduct a proper risk assessment, overlooking suicidal ideation and acute mental health deterioration, leading to inappropriate discharge without medication review or escalation.
Action taken summary The Trust has strengthened its psychiatric liaison service at King's College Hospital ED by extending hours to 24/7, introducing comprehensive training, increasing staff, and launching a new ED Low In
Malik Bunton
All Responded
2025-0519 15 Oct 2025 North Yorkshire and York
Ministry of Defence
Concerns summary Inadequate inquiry into a previous incident, flawed clinical review processes, and deliberate obstructions to evidence gathering impeded the RAF's ability to assess suicide risk and learn lessons.
Action taken summary The Ministry of Defence has issued further direction and guidance to avoid delays in providing statements for service inquiries. A new process has been directed for all suspected suicides to be subjec
Abigail Jelley
All Responded
2025-0509 13 Oct 2025 Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Healthcare
Concerns summary Community Mental Health Teams lack mandatory perinatal red flag training and professional curiosity, exacerbated by cultural issues and structural leadership problems, risking inappropriate care for vulnerable mothers.
Action taken summary The Trust has established multidisciplinary team (MDT) huddle meetings, weekly MDT reviews, and provided senior clinical leadership to support staff. They are also rolling out a redesigned training pr
Jack Peatling
All Responded
2025-0510 13 Oct 2025 Essex
Department of Health and Social Care NHS England
Concerns summary A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.
Action taken summary NHS England has made £75 million available for local systems to improve bed capacity and developed a national mental health and children and young people’s bed management platform. They are also intro
Jillian Steedman
All Responded
2025-0506 10 Oct 2025 Essex
Essex County Council Essex Partnership NHS Foundation Trust
Concerns summary Failures in information sharing, incomplete care plans, and inadequate risk assessments led to an inappropriate discharge placement that was not adequately monitored, despite repeated crises and professional warnings.
Action taken summary Essex County Council has undertaken joint work with EPUT resulting in an updated PSIRF Policy. They are reviewing Mental Health Act obligations and their Approved Mental Health Professional service, a
Leo Barber
All Responded
2025-0505 9 Oct 2025 South London
Google UK & Ireland
Concerns summary Vulnerable children can access online suicide material, and international service providers’ jurisdictional stance can obstruct coronial investigations, hindering efforts to prevent future deaths.
Action taken summary Google details its existing safety measures for suicide and self-harm content on Google Search and notes that the report did not suggest the content was found via their search engine. Regarding data a
Imogen Nunn Prevention of future deaths report
All Responded
2025-0494 7 Oct 2025 West Sussex, Brighton and Hove
Cabinet Office, 1 Horse Guards Road Caxton House Department for Work and Pensions +8 more
Concerns summary A national shortage and lack of regulation for British Sign Language interpreters, alongside procurement issues and few BSL-proficient clinicians, create significant risks for deaf mental health patients.
Action taken summary The Department for Education acknowledges concerns regarding BSL interpreter shortages and procurement, but maintains the government's preference for industry self-regulation. The Minister will raise
Angela Thompson
All Responded
2026-0027 7 Oct 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
HM Prison & Probation Service
Concerns summary A lack of liaison between prison and community psychiatric services for released prisoners with ongoing mental health issues, especially when geographically distant, creates risks for continuity of care.
Action taken summary HMPPS has established Regional Health & Justice Teams and a central Deaths Under Supervision Team to improve integrated health services and liaison for prison leavers. Learning from this case will be
Naomi Aylott
All Responded
2025-0522 29 Sep 2025 Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Healthcare
Concerns summary The patient received no face-to-face care due to geographical distance, and the CMHT had inadequate risk assessment training, auditing, and family involvement in remote care.
Action taken summary The Trust has remedied a data capture issue for carer information, with the data now captured on their visualisation platform, and is achieving greater alignment in the Carers function post-merger.
Christian Marsh Prevention of future deaths report
All Responded
2025-0471 16 Sep 2025 West Yorkshire (East)
Leeds Survivor-Led Crisis Service (Leed… Leeds and Yorkshire Partnership Foundat…
Concerns summary There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating significant risk.
Action taken summary Leeds and Yorkshire Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis Service have implemented a standardised daily handover template and daily 'huddle' meetings to improve formal communi
Charlotte Tetley
All Responded
2025-0465 14 Sep 2025 Cheshire
Chief Constable of Cheshire Police
Concerns summary A narrow police policy interpretation requires explicit intent to end life for high-risk missing person response, while ambulance services decline calls if whereabouts are unknown, increasing risk of death.
Action taken summary Cheshire Constabulary explains their 'Right Care, Right Person' policy and states that the hospital's subsequent enquiries led to them determining no further concerns, thereby withdrawing their reques
Charlotte Tetley
All Responded
2025-0466 14 Sep 2025 Cheshire
Cheshire and Wirral Partnership NHS Tru…
Concerns summary A patient was prematurely removed from the inpatient bed list before an appropriate daily mental health review, despite documented need for admission, risking patient safety.
Action taken summary Cheshire and Wirral Partnership NHS Foundation Trust has implemented system changes including direct documentation of Clinical Prioritisation Meeting outcomes, establishing a Patient Flow Meeting, dev
James Cochrane
All Responded
2025-0454 5 Sep 2025 Rutland and North Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary There is no clear guidance for mental health staff on using alternative evidence formats like video footage or on ensuring carers are adequately equipped to support patients at home.
Action taken summary The Trust has updated its carer feedback form, developed a new safety and preventative care plan to incorporate carers' views, and implemented welcome and carer information packs. They also plan to la
Khalif Mohammed
All Responded
2025-0452 4 Sep 2025 Birmingham and Solihull
Home Office
Concerns summary West Midlands Police experienced significant delays in allocating officers to a priority case due to insufficient resources, posing a risk of future deaths.
Action taken summary The Home Office has significantly increased police funding, with West Midlands Police receiving an additional £56.5 million for 2025-26. National initiatives include £120 million in-year funding and £
Jessica Smithson
All Responded
2025-0415 8 Aug 2025 Manchester North
Department of Health and Social Care NHS England Greater Manchester Integrated Care Board
Concerns summary The delayed rollout of national 24/7 crisis text services leaves a critical gap, with charities filling the void inconsistently, leading to varied support, challenges in police response, and limited integration with NHS mental health pathways.
Action taken summary NHS England has requested all Integrated Care Boards (ICBs) to establish integrated crisis text services, with ICBs having submitted their plans and delivery expected across all areas by Spring 2026.
Gareth Jackson
All Responded
2025-0417 8 Aug 2025 Inner West London
South West London and St Georges Mental…
Concerns summary Inadequate handover and record-keeping on a psychiatric ward led to a high-risk suicidal patient being permitted unescorted leave, contrary to the safety plan. A national bed crisis also delayed transfer.
Action taken summary South West London and St George’s Mental Health NHS Trust has reviewed and updated its Acute Ward Operational and Leave Policies, and introduced new Day 2 checklists and Mental Health Act documentatio
Simon Moore
All Responded
2025-0404 5 Aug 2025 Dorset
Network Rail
Concerns summary A lack of communication protocol meant critical welfare information from a distressed train driver was not relayed from the signaller to the attending Driver Manager, hindering timely mental health assessment.
Action taken summary Network Rail has developed and implemented a new Code of Practice on Welfare Communication for train drivers involved in SPADs and established an Industry Working Group on Welfare Communication to rev
Sidi Bojang
All Responded
2025-0436 1 Aug 2025 North London
Department of Health and Social Care
Concerns summary Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.
Action taken summary NHS England has strengthened 24/7 mental health liaison services in all Type 1 Emergency Departments and published the Men's Health Strategy. They are also working towards consultant-led assessments a
Samantha Young
All Responded
2025-0375 25 Jul 2025 Hampshire, Portsmouth and Southampton
Department of Health and Social Care Hampshire and Isle of Wight Healthcare …
Concerns summary A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.
Action taken summary Hampshire and Isle of Wight Healthcare NHS Foundation Trust has remedied a data capture issue related to carer information and is designing a new risk assessment training programme for all staff, incl
Michael Pugh
All Responded
2025-0378 25 Jul 2025 Kent and Medway
His Majesty’s Prison and Probation Serv…
Concerns summary Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
Action taken summary HM Prison and Probation Service states that existing POELT and local induction training covers ACCT processes. Going forward, HMP Swaleside will promote its online Safety Learning Reference Library, i
Leia Sampson-Grimbly
All Responded
2025-0381 25 Jul 2025 North London
Department of Health and Social Care Tavistock and Portman NHS Foundation Tr…
Concerns summary Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.
Action taken summary The Trust noted the concern about long waiting lists for Gender Dysphoria clinics, explaining that NHS England has been unable to commission sufficient capacity due to a lack of specialist staff and i
Isaac Ingle-Gillis
All Responded
2025-0373 22 Jul 2025 Gwent
Aneurin Bevan University Health Board
Concerns summary The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.
Action taken summary The Health Board has commenced work to broaden secondary care practitioners' access to the summary GP record via the Welsh Clinical Portal, including for the Crisis Resolution and Home Treatment Team.
Jairus Earl
All Responded
2025-0349 10 Jul 2025 Dorset
Department of Health and Social Care Home Office
Concerns summary Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a risk of future deaths.
Action taken summary The NPCC commenced an additional two-day course in June 2025 for Firearms Licensing Enquiry Officers, focusing on domestic abuse, family turmoil, mental health, and wellbeing. They also clarified the
Andrew Kenward
All Responded
2025-0346 9 Jul 2025 Surrey
Department of Health and Social Care Home Office
Concerns summary There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or consideration for dilution, posing significant risk.
Action taken summary The Home Office is researching the availability of sodium nitrite and collaborating with DHSC on legislative options. Border Force issued guidance last year on controlling items intended to assist sui