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
PFD Reports
841 results
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
NHS England Department of Health and Social Care
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 Partnership NHS Foundation Trust Essex County Council
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
Stella LeClaire
No Identified Response
2025-0619 9 Oct 2025 Northamptonshire
Secretary of State for Health and Socia… Secretary of State for the Home Departm…
Concerns 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.
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.
Steven Hart
Partially Responded
2025-0487 24 Sep 2025 Bedfordshire and Luton
CEO of HMPPS [REDACTED] Governor [REDACTED] HM Chief Inspector of Prisons [REDACTED]
Concerns 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 summary HM Prison and Probation Service has implemented interim measures by replacing ligature-resistant cell observation panels at HMP Bedford and completed a full review of all LR doors. Handover procedures
Christopher Bird
Partially Responded
2025-0477 23 Sep 2025 Wiltshire and Swindon
White Horse Medical Practice NHS England Oxford Health NHS Foundation Trust
Concerns 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.
Action taken summary NHS England clarifies that the email in question was recovered from a recoverable-items folder, indicating user deletion rather than system failure. It explains that NHSmail is a secure platform with
Martin Collins
Partially Responded
2025-0497 17 Sep 2025 Suffolk
Minister of State for Prisons Probation and Reducing Reoffending
Concerns 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 taken summary HM Prison and Probation Service confirms initial discussions are underway with BT to explore the technical feasibility of implementing automated monitoring of prisoner call volumes, with this work to
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
Brian Burrows
Partially Responded
2025-0459 9 Sep 2025 West Yorkshire (East)
HMP Leeds Governing Governor
Concerns 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 taken summary HM Prison and Probation Service is reforming foundation training for prison officers to focus on experiential learning including dynamic risk assessment, and HMP Leeds will implement High Reliability
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
Victoria Taylor
No Identified Response CC
2025-0455 5 Sep 2025 North Yorkshire and York
Tees, Esk and Wear Valleys NHS Foundati…
Concerns 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.
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 £
Charles Stonley
Partially Responded
2025-0432 20 Aug 2025 Liverpool and Wirral
Health Services Safety Investigations B… National Director FOR Mental Health Deputy Director of Patient Safety NHS E… +1 more
Concerns summary Limited resources and a severe shortage of mental health beds mean vulnerable patients in crisis are left in Emergency Departments for prolonged periods, increasing their risk of self-harm and death.
Action taken summary NHS England has tasked local health systems to improve patient flow and reduce long waits in mental health crisis pathways, and is developing a national patient safety toolkit for EDs. The Department
Emily Hewerdine
Partially Responded
2025-0431 18 Aug 2025 Nottingham and Nottinghamshire
Doncaster and Bassetlaw Teaching Hospit… Chief Executive
Concerns summary Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.
Action taken summary The Trust has implemented a Safety Improvement Plan, introduced weekly audits using the Tendable application, and is transitioning to electronic fluid balance charting with ongoing staff training. Add
Chloe Barber
Partially Responded
2025-0421 12 Aug 2025 City of Kingston Upon Hull and the County of the East Riding of Yorkshire
NHS England Department of Health and Social Care Royal College of Psychiatrists
Concerns summary Critical gaps exist in transitional care pathways from CAMHS to adult services, along with unclear guidelines for administering antipsychotic depots and a poor understanding of Mental Health Act aftercare provisions.
Action taken summary NHS England has invested in Integrated Care Boards to strengthen services for young adults and implemented the updated GMC's Good Medical Practice guidance (Jan 2024) and statutory guidance on mental
Jessica Smithson
All Responded
2025-0415 8 Aug 2025 Manchester North
NHS England Greater Manchester Integrated Care Board Department of Health and Social Care
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