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
Saranveer Sihota
All Responded
2025-0540 23 Oct 2025 Derby and Derbyshire
Chesterfield Borough Council
Concerns summary (AI summary) The building's low top-floor wall presents a clear and known risk of fatal falls, especially for individuals with suicidal thoughts, with multiple similar incidents reported.
Action Taken (AI summary) Following a death, Chesterfield Borough Council closed the top floor of a car park and installed full-height, heavy-duty gates and fencing to prevent unauthorized access. Suicide prevention measures were also built into the construction of a newer car park.
Steven Davidson
All Responded
2025-0536 21 Oct 2025 Essex
HCRG Care Group
Concerns summary (AI summary) Healthcare staff at HMP Chelmsford lack proficiency in navigating System One records to find critical past self-harm information, or are unaware of its importance during prisoner health assessments, indicating training deficiencies.
Action Taken (AI summary) HCRG Care Group has amended its training provision so that all new staff receive structured SystmOne training as part of their induction and will provide refresher training to existing staff within three months. The Performance and Quality teams are embedding SystmOne training into existing governance and supervision processes.
Scott Berry
All Responded
2026-0038 20 Oct 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
HM Prison & Probation Service Minister of State for Prisons, Parole a…
Concerns summary (AI summary) Imprisonment for Public Protection (IPP) prisoners face profound hopelessness and mental health suffering due to indefinite detention and lack of access to parole reviews or rehabilitative programs, increasing suicide risk.
Action Taken (AI summary) HMPPS has implemented several measures to support IPP prisoners, including establishing a centralised shared folder for training materials, delivering refresher training to PPCS senior managers, and beginning a recall referral trial.
Stuart Fowkes
All Responded
2025-0527 20 Oct 2025 The Black Country
Devon & Cornwall Police
Concerns summary (AI summary) Devon and Cornwall Police failed to share vital information regarding the deceased's suicidal intent with West Midlands Police, leading to critical risk information being missed in subsequent actions.
Action Taken (AI summary) Devon and Cornwall Police have updated their policy to include specific requirements for information sharing with other forces regarding vulnerable individuals, including those travelling into or out of the area, and information from sources like ANPR.
Alexander McCormack
All Responded
2025-0548 19 Oct 2025 Northamptonshire
Northamptonshire Police
Concerns summary (AI summary) Inefficient transfer of missing persons cases between police forces due to inadequate training for transferees on data import procedures, risking delays in risk assessment and investigation.
Action Planned (AI summary) Northamptonshire Police is creating new training presentations for all ranks, including existing Cadre Inspectors, FCR Inspectors and Detective Inspectors, regarding COMPACT transfer training; the Detective Superintendent for Protecting Vulnerable People will ensure that our Learning and Development team provide COMPACT transfer training to all future transferee Inspectors.
Owen Donnelly
Partially Responded
2025-0532 17 Oct 2025 Manchester West
Department of Health and Social Care Home Department
Concerns summary (AI 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 Planned (AI summary) The Home Office states that the Border Security, Asylum and Immigration Bill, currently in the House of Lords, will make it a criminal offence to import, make, adapt, supply, or offer to supply components that can be used to manufacture prohibited weapons.
Malik Bunton
All Responded
2025-0519 15 Oct 2025 North Yorkshire and York
Ministry of Defence
Concerns summary (AI 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 (AI summary) The RAF has directed that all suspected suicides will now be subject to an immediate fact-finding investigation, formally brought into the RAF Postvention Suicide Response policy. Further direction and guidance has been issued to ensure delays in providing statements to the Service Inquiry panel are avoided in the future, and the Defence Inquests Unit is working to implement a process to retain email accounts of deceased service personnel.
Tony Duncan
All Responded
2025-0516 15 Oct 2025 City of London
South London and Maudsley NHS Foundatio…
Concerns summary (AI 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 (AI summary) The Trust has implemented changes including: mandatory training for staff on comprehensive risk assessments, a revised policy on recording risk factors, the introduction of a new care model, and the launch of a new ED Low Intensity Area in partnership with SLAM.
Jack Peatling
All Responded
2025-0510 13 Oct 2025 Essex
Department of Health and Social Care NHS England
Concerns summary (AI 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 Planned (AI summary) NHS England is making £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements. The therapeutic acute inpatient operating model for adults and older adults, will be introduced. The Department of Health and Social Care outlines plans to reduce mental health waiting times, improve management of bed capacity, and expand community mental health services. It has committed £26 million in capital investment to open new mental health crisis centres.
Abigail Jelley
All Responded
2025-0509 13 Oct 2025 Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Healthcare
Concerns summary (AI 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 (AI summary) The Trust is rolling out a redesigned training programme for assessing and managing all risk in mental health, and perinatal risks will be part of that programme. Multidisciplinary team (MDT) "huddle" meetings are now established and provide a forum for clinicians to discuss referrals and caseloads.
Jillian Steedman
All Responded
2025-0506 10 Oct 2025 Essex
Essex County Council Essex Partnership NHS Foundation Trust
Concerns summary (AI 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 Planned (AI summary) Essex County Council will revise the Section 117 policy, undertake a full review of community mental health social work arrangements, and examine the operational configuration of their Approved Mental Health Professional service. Essex Partnership University NHS Foundation Trust held a debrief regarding information sharing, implemented structured professional supervision, reviewed the lone worker policy, provided additional training to staff, and introduced a new role to strengthen patient safety incident reports.
Stella LeClaire
All Responded
2025-0619 9 Oct 2025 Northamptonshire
Secretary of State for Health and Socia… Secretary of State for the Home Departm…
Concerns summary (AI summary) The rising number of deaths from a substance sold for suicide raises concerns, emphasizing the need for routine toxicological analysis to improve evidence for potential prosecutions against suppliers.
1 response from Department of Health and Social Care
Leo Barber
All Responded
2025-0505 9 Oct 2025 South London
Google UK & Ireland
Concerns summary (AI 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 Planned (AI summary) Google makes available an Inactive Account Manager tool, which allows users to designate third parties to receive parts of their account data in the event of their death or inactivity and are engaging actively with Ofcom and the Department for Science, Innovation and Technology on issues regarding access to information relevant to an inquest.
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 (AI 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 (AI summary) HMPPS has Regional Health & Justice Teams to improve integrated health services and a central Deaths Under Supervision Team to improve liaison between prison and community teams; learning from the death will be shared across HMPPS regions. HMPPS has Regional Health & Justice Teams to improve integrated health services and a central Deaths Under Supervision Team to improve liaison between prison and community teams; learning from the death will be shared across HMPPS regions.
Imogen Nunn Prevention of future deaths report
Partially Responded
2025-0494 7 Oct 2025 West Sussex, Brighton and Hove
Cabinet Office, 1 Horse Guards Road, Lo… Minister of State for Education, Depart… Minister of State, Minister for Social … +1 more
Concerns summary (AI 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 Planned (AI summary) The Minister for Women and Equalities will raise concerns regarding procurement practices and the status of British Sign Language (BSL) interpreters with the BSL Advisory Board, asking them to work with NRCPD to consider ways to improve the profession.
Naomi Aylott
All Responded
2025-0522 29 Sep 2025 Hampshire, Portsmouth and Southampton
Hampshire and Isle of Wight Healthcare
Concerns summary (AI 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 (AI summary) The Trust is reviewing its community mental health team structure, improving access to face-to-face appointments, developing new systems for carers, and commissioning an independent audit regarding carer engagement and has remedied the data issue with the information now captured on their data insights visualisation platform.
Steven Hart
All Responded
2025-0487 24 Sep 2025 Bedfordshire and Luton
Governor [REDACTED], HM Chief Inspector…
Concerns summary (AI summary) Systemic failings included an unmonitored ligature point in a 'safer cell,' inadequate communication of mental state risks during handovers, and observations not being carried out to standard, contributing to the death.
Action Taken (AI summary) HMPPS has implemented interim measures at HMP Bedford, including replacing ligature-resistant cell observation panels with lockable hatches. Handover procedures have been strengthened, and a robust quality assurance process introduced for ACCT observations, with additional training and support provided to staff.
Christopher Bird
Partially Responded
2025-0477 23 Sep 2025 Wiltshire and Swindon
NHS England Oxford Health NHS Foundation Trust White Horse Medical Practice
Concerns summary (AI summary) Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns between secondary and primary care.
Noted (AI summary) NHS England explains the NHSmail system's security and audit capabilities, noting that an email was recoverable and providing advice to the GP practice on future searches for missing documentation. They also describe the internal process for reviewing PFD reports. Oxford Health NHS Foundation Trust will complete a review to identify changes to current AMHT practice that may prevent the risk of a GP not receiving timely communications from the AMHT, with a wider consultation with GP representatives and the Integrated Care Board.
Martin Collins
All Responded
2025-0497 17 Sep 2025 Suffolk
Minister of State for Prisons, Probatio…
Concerns summary (AI summary) The prison telephone system lacks automated monitoring for unusual call volumes and there's no system for manual oversight, leading to missed opportunities to identify risk triggers and prevent suicide.
Action Planned (AI summary) HMPPS has initiated discussions with BT to explore the feasibility of monitoring call volumes as a potential indicator of heightened suicide/self-harm risk as part of an ongoing development project. They emphasize that any technical solution would be an additional tool to their existing holistic approach, including ACCT and the Listener scheme.
Christian Marsh Prevention of future deaths report
All Responded
2025-0471 16 Sep 2025 West Yorkshire (East)
Leeds and Yorkshire Partnership Foundat… Leeds Survivor-Led Crisis Service (Leed…
Concerns summary (AI 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 (AI summary) Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis Service have jointly developed a standardised daily handover template and implemented daily 'huddle' meetings for patients admitted to the respite facility. Additional measures include joint referral points, book-in meetings, joint reviews, weekly interface meetings, recommencement of operations meetings, and Clinical Improvement Forum meetings.
Charlotte Tetley
All Responded
2025-0466 14 Sep 2025 Cheshire
Cheshire and Wirral Partnership NHS Tru…
Concerns summary (AI 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 (AI summary) The Trust has implemented several system changes, including documenting Clinical Prioritisation Meeting outcomes in SystmOne, establishing a Patient Flow Meeting, inviting clinicians to the Clinical Prioritisation Meeting, developing an SOP for Escalation of Clinical Differences, undertaking reflective supervision with the Mental Health Practitioner involved, and reinforcing training around record keeping, communication, and risk-informed decision-making.
Charlotte Tetley
All Responded
2025-0465 14 Sep 2025 Cheshire
Chief Constable of Cheshire Police
Concerns summary (AI 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.
Noted (AI summary) Cheshire Constabulary provides background information on the Right Care, Right Person policy and explains their actions in this specific case, noting that hospital staff made further enquiries and determined they no longer required police assistance.
Brian Burrows
All Responded
2025-0459 9 Sep 2025 West Yorkshire (East)
Governing Governor, HMP Leeds
Concerns summary (AI summary) Prison officers lack training and guidance on decision-making when faced with competing emergency tasks like multiple cell bells and ACCT checks, risking inadequate responses.
Action Planned (AI summary) HMPPS is implementing the 'Enable' program, a workforce transformation initiative with Foundation Training Reform to improve officer training and support, including dynamic risk assessment. HMP Leeds will implement High Reliability Checklist Briefings across all wings and introduce a new Supervising Officer (Wellbeing, Care and Coaching) role to provide enhanced support.
Victoria Taylor
No Identified Response CC
2025-0455 5 Sep 2025 North Yorkshire and York
Tees, Esk and Wear Valleys NHS Foundati…
Concerns summary (AI summary) Secondary mental health services failed to offer appropriate trauma-informed treatment pathways or initiate a multi-agency approach for a patient with acknowledged childhood trauma and complex needs.
James Cochrane
All Responded
2025-0454 5 Sep 2025 Rutland and North Leicestershire
Leicestershire Partnership NHS Trust
Concerns summary (AI 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 (AI summary) The Trust has implemented several changes, including ensuring carers' views can be documented with consent, incorporating carer perspectives into safety plans, and updating risk assessment documentation to include carer input. They also provide support to carers via signposting and offer a Carers pack, and are launching a course for carers through the Leicestershire Recovery College.