Suicide
PFD Category
Reports: 841
Areas: 72
Earliest: Feb 2015
Latest: 12 Mar 2026
83% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 26% from 117 (2023) to 148 (2024).
PFD Reports
841 resultsSteven Cooke
Historic (No Identified Response)
2020-0302
30 Dec 2020
Stoke-on-Trent and North Staffordshire Coroner’s Court
NHS England
Concerns summary
There is no national guidance for mental health professionals to engage with patients' families, hindering the collection of a full medical picture.
Tina Murray
All Responded
2020-0296
22 Dec 2020
Blackpool and Fylde
Belgravia Care Home Ltd
Concerns summary
A care home failed to prevent a vulnerable resident from accessing plastic bags, despite staff awareness of self-harm risk, indicating a systemic failure in removing means of harm.
Andrew Gibbins
All Responded
2020-0290
17 Dec 2020
Suffolk
Norfolk and Suffolk Foundation Trust
West Suffolk Hospital and The Wedgewood…
Concerns summary
A security guard's concern about a patient expressing suicidal feelings was not reported to clinical staff at the hospital, leading to a missed opportunity for assessment.
Christopher Swain
All Responded
2020-0284
14 Dec 2020
West Sussex
Sussex Partnership NHS Foundation Trust
Concerns summary
Inconsistent patient observation practices, inadequate mental health reviews, risk assessments, and record-keeping were identified. There was also a failure to provide staff escorts for sectioned patients being transferred.
Claire Lilley
All Responded
2020-0297
11 Dec 2020
Inner London South
Oxleas NHS Trust
Concerns summary
Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Rory Attwood
All Responded
2021-0086
10 Dec 2020
Gwent
Aneurin Bevan University Health Board
Concerns summary
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Samuel Morgan
All Responded
2020-0276
9 Dec 2020
Swansea and Neath Port Talbot
Department of Health and Social Care
Medicines and Healthcare products Regul…
Concerns summary
Patient information leaflets for SSRIs lack immediate, high-impact warnings, such as a "Black Box Warning," to clearly highlight the increased risk of suicidal thinking in young adults.
Kimberley Smith
All Responded
2020-0279
9 Dec 2020
Surrey
Surrey and Borders Partnership NHS Foun…
Concerns summary
The Trust lacks clear written policies for managing informal patients' leave requests, including risk assessments and monitoring. A vital recommendation for a comprehensive alcohol detoxification protocol also remains unimplemented.
Roy Curtis
All Responded
2020-0272
4 Dec 2020
Milton Keynes
Milton Keynes Council and Social Servic…
Concerns summary
Overly bureaucratic procedures for urgent adult social care assessments fail to provide necessary priority, delaying critical support for vulnerable individuals.
Agnès Marchessou
Historic (No Identified Response)
2020-0255
26 Nov 2020
Inner North London
Metropolitan Police
Concerns summary
Police officers failed to communicate critical information about the deceased's stated suicidal intent to medical staff, neglected to search police systems for relevant history, and did not reflect on their procedural errors.
Neville Bardoliwalla
All Responded
2020-0258
26 Nov 2020
North London
Department of Health and Social Care
Concerns summary
A lack of a process for collecting and disposing of prescribed controlled medication allowed for its accumulation, posing a significant risk.
Lee Elliott
All Responded
2020-0265
26 Nov 2020
County of Cumbria
Department of Health and Social Care
Concerns 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.
Sharon Kelly
Partially Responded
2020-0250
24 Nov 2020
Essex
EFAS
Essex Partnership University NHS Founda…
Essex Police
Concerns summary
Inadequate training and unclear communication protocols between emergency services led to delays in identifying and responding to mental health crisis risks, including police attendance and urgent mental health assessments.
David Ball
All Responded
2020-0251
24 Nov 2020
Derby and Derbyshire
NHS Digital
NHS England
Concerns summary
Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.
Jason Thompson
All Responded
2020-0246
20 Nov 2020
County Durham and Darlington
Metalchem Ltd
Department of Health and Social Care
eBay UK Ltd
Concerns summary
A website may be illegally promoting suicide methods, and a lethal substance is too easily available online under a misleading description, posing significant public safety risks.
Paul Hills
Partially Responded
2020-0247
19 Nov 2020
North East Kent
Ministry of Defence
Woolwich Station Medical Centre
Concerns summary
Inadequate mental health care during COVID-19 involved no risk assessment for virtual appointments, outdated care plans, failure to share escalating risks with family, and poor documentation of suicidal disclosures.
Imane Bouasbia
Partially Responded
2020-0234
12 Nov 2020
East London
Metropolitan Police Service
Home Office
Concerns summary
Police failures included inadequate communication of suicidal ideation during handover, absence of a risk assessment for self-harm, and a limited, non-expedited response to a direct suicidal text message.
Xuanze Piao
All Responded
2020-0230
11 Nov 2020
Coventry
Coventry University
Concerns summary
The university failed to hold a face-to-face meeting or contact the guardian/parents of an under-18 overseas student before sending a critical email indicating course removal risk, revealing a lack of clear communication policy.
REDACTED
Unknown
9 Nov 2020
Surrey
Concerns summary
The deceased's general practitioner was not invited to MARAC meetings, nor informed of domestic violence allegations or care proceedings, hindering effective mental health treatment.
Christopher Murfet
All Responded
2020-0273
6 Nov 2020
Lincolnshire
United Lincolnshire Hospitals Trust
Concerns summary
Procedures for considering sectioning the deceased under the Mental Health Act were unclear or potentially absent, despite a risk of suicide.
Darrell Sharples
All Responded
2020-0219
28 Oct 2020
Cornwall and the Isles of Scilly
Devon and Cornwall Constabulary
Concerns summary
A mental health clinician conducting telephone triage was unfamiliar with key Trust policies and guidance, resulting in an inadequate assessment of a high-risk patient.
Martin Barrett
All Responded
2020-0222
27 Oct 2020
North East Kent
Priory Group
Concerns summary
When internal referrals are declined, patients are not directly informed or given safety netting advice, particularly with insurance funding, leaving high-risk individuals without immediate alternative treatment or support.
Thomas King
All Responded
2020-0207
15 Oct 2020
Essex
Essex Partnership University NHS Founda…
Concerns summary
Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
Piotr Kierzkowski
All Responded
2020-0204
12 Oct 2020
Suffolk
Department of Health and Social Care
Concerns summary
A critical lack of available mental health beds prevented the deceased from informal admission despite mutual desire from patient and staff, leading to his tragic death.
Emily Greene
All Responded
2020-0288
6 Oct 2020
South Yorkshire West
South Yorkshire Police HQ
Concerns summary
Failures in police investigation of a sexual assault included employing untrained officers, mishandling referrals, poor victim communication, and inadequate facilities, compounded by mishandling a missing person's report.