Suicide

PFD Category

Reports: 845 Areas: 72 Earliest: Feb 2015 Latest: 24 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).

Responded 696 No Response 13 Historic 112 Pending 18

Action Taken 55%

Action Planned 23%

Noted 14%

Disputed 8%

Based on 752 classified responses

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PFD Reports

614 results

Aleysha McLoughlin

2015-0136 8 Apr 2015 Manchester (West)

Communities & Local Government Department for Education Department of Health and Social Care +1 more

Concerns summary The training system for professionals working with young people regarding self-harm requires a comprehensive review, as self-harm is a growing public health crisis.

Brenda Leyland

2015-0112 20 Mar 2015 Leicester (City & South)

Department of Health and Social Care

Concerns summary Helium gas canisters are freely available in large volumes without purchase controls or modified valves to restrict gas release, posing an uncontrolled risk.

Alasdair Penny

2015-0106 17 Mar 2015 West Sussex

West Sussex County Council Sussex Police

Concerns summary Bridge railings are easily mounted, facilitating suicides. Despite existing support notices, physical barriers should be reconsidered to prevent spontaneous jumps from the bridge.

Kimberley Parsons

2015-0077 4 Mar 2015 Avon

Avon and Wiltshire Mental Health Partne… Care Quality Commission

Concerns summary Unjustified advice on 'assisted self-harming' was given without research backing, consultant approval, or documentation, indicating a lack of clear protocols for novel treatments and training failures.

James Taylor

2020-0300 East London

Continuing Care Redbridge Clinical Commissioning Group …

Concerns summary Inadequate transfer summaries between GP practices for complex patients lead to critical clinical information being missed and compromise continuity of care.

Action taken summary Barking Dagenham Havering and Redbridge CCG, in collaboration with NELFT, has implemented changes to psychological therapies service procedures, increased service capacity, and updated panel protocols

Mina Topley-Bird

2021-0100 County Durham and Darlington

West Park Hospital Department of Health and Social Care

Concerns summary Inadequate IT systems hindered uploading medical records and printing documents in shared premises. Furthermore, patient safety assessments for ligature points were unconfirmed, and risk assessment processes remained incomplete.

Action taken summary Tees, Esk and Wear Valleys NHS Foundation Trust immediately implemented a checklist for Accident and Emergency patients from outside the area to ensure information gathering and sharing. They are also

Louise Allen

2022-0159 East London

North East London NHS Foundation Trust …

Concerns summary An inadequate care plan resulted from severe failings in care coordination, stemming from insufficient, underpaid, and overworked care co-ordinators facing high caseloads and staff turnover.

Action taken summary The Trust conducted a pay review in July 2021, upgrading all Band 5 Nurses to Band 6, and gave a £1000 payment to Band 6 Care Coordinators in October 2021. They have also agreed to recruit eight addit

Samuel Gomm

2022-0163 South Wales Central

Powys County Council Powys Teaching Health Board

Concerns summary The WARRN risk assessment tool for self-harm lacked optimal visibility and update mechanisms for fluctuating risks, potentially causing new users to underestimate risk and miss referral opportunities.

Action taken summary Powys County Council and Powys Teaching Health Board have fully implemented the WARRN risk assessment tool in Community Mental Health Teams, with full integration into inpatient Electronic Patient Rec

Andrew Nixon

2022-0165 Dorset

Somerset NHS Foundation Trust

Concerns summary Family/carers were not fully involved in mental health risk assessments or care planning, and there was no clear criteria for conducting a Carer's Assessment, limiting protective factors.

Action taken summary NHS Somerset has issued new staff briefings and posters on consent and confidentiality, updated clinical risk training content, and established a policy requiring co-produced safety plans shared with

Kate Hyatt

2022-0192 West Yorkshire (Western)

Hands of Light Academy

Concerns summary A 'Hands of Light Academy' allegedly dispenses hallucinogenic substances to attendees, including potentially mentally unwell individuals, without proper consideration for their impact, especially on psychosis sufferers.

Action taken summary Hands of Light Academy disputes that the deceased attended their courses or that they dispense hallucinogens, stating a review of records shows no attendance on the dates specified. They commit to con

Alun Davies

2022-0196 Hampshire, Portsmouth and Southampton

South Western Railway and BTP Fatal Inv…

Concerns summary Portchester Railway Station has limited staffing, CCTV, and poor visibility despite being an escalated location with multiple fatalities. Previous safety recommendations remain unaddressed, and public welfare announcements are lacking.

Action taken summary South Western Railway has rejected increasing staffing levels, RCO patrols, and 24/7 CCTV surveillance at Portchester Station, stating existing measures are adequate. They have already installed tresp

Dominic Noble

2022-0204 West Yorkshire (Eastern)

Practice Plus Group Health and Rehabili…

Concerns summary HMP Leeds has insufficient psychiatric doctor provision, leading to significant delays in assessments and treatment for prisoners with severe mental health issues, a persistent concern.

Action taken summary Practice Plus Group is actively seeking to recruit a permanent consultant psychiatrist for HMP Leeds and has submitted a business case to NHS England for additional funding to increase psychiatric cli

Ami Mitchell

Avon and Wiltshire Mental Health Trust

Concerns summary Despite persistent suicidal ideation, severe delusions, hallucinations, and requests for admission, the patient received no formal diagnosis, escalation of care, or hospital admission.

Action taken summary Avon and Wiltshire Mental Health Partnership has reviewed diagnostic processes and appointed a Consultant medical lead for diagnosis in South Gloucestershire to ensure all service users receive a form

Hannah Booth

2025-0615 Derby and Derbyshire

NHS England Sett Valley Medical Centre Derbyshire Community Health Services NH… +2 more

Concerns summary Fragmented IT systems and poor information sharing between and within services meant crucial mental health information about the mother was not readily accessible or understood.

Action taken summary The Trust has implemented an auto-consultation function in SystmOne to cross-reference mother and baby notes, briefed locality managers on inquest findings, and shared a document clarifying record-kee