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).

Response Status
Responded 696 No Response 13 Historic 112 Pending 18
AI Classification
Action Taken 55%
Action Planned 23%
Noted 14%
Disputed 8%
Based on 752 classified responses
Reports by Quarter
PFD Reports
845 results
REDACTED
Partially Responded
2022-0036 5 Nov 2018 London Inner South
General Medical Council Broadgate General Practice
Concerns summary A GP failed to adequately inquire into psychiatric history, made inappropriate medication changes, prescribed excessive quantities, and demonstrated poor record-keeping, missing opportunities for urgent psychiatric referral.
Patricia Chambers
Historic (No Identified Response)
2018-0350 4 Nov 2018 London (West)
Shepherds Bush Medical Centre West London Mental Health Trust
Concerns summary Concerns were identified regarding practices at West London Mental Health Trust, indicating a risk of future deaths if appropriate action is not taken.
Colette Dunn
Historic (No Identified Response)
2018-0337 1 Nov 2018 Milton Keynes
Milton Keynes Clinical Commissioning Gr…
Concerns summary A full Mental Health Act assessment was omitted before discharge despite police concerns. A lack of clear discharge protocols between agencies and inadequate facilities for mental health crisis intervention were identified.
Billie Lord
All Responded
2018-0338 1 Nov 2018 Milton Keynes
Milton Keynes Clinical Commissioning Gr…
Concerns summary The mental health inpatient facility uses inappropriate three-bedded dormitories, which contributed to patient stress and requires modernization according to Royal College of Psychiatrists' recommendations.
David Sargeant
All Responded
2018-0312 25 Oct 2018 Cornwall & the Isles of Scilly
Kernow Clinical Commissioning Group
Concerns summary The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, and impracticalities of out-of-county referrals for ongoing care.
Jennifer Lacey
Partially Responded
2018-0315 24 Oct 2018 London Inner (West)
GPC NHS England
Concerns summary Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled by UK pharmacies without adequate checks.
Thomas Lear
Unknown
11 Oct 2018 Stoke-on-Trent and North Staffordshire
Concerns summary A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile went unaddressed due to no out-of-hours coverage.
Robin McEwan
All Responded
2018-0325 10 Oct 2018 North Yorkshire
Harrogate & Rural District Clinical Com…
Concerns summary Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Michael Cooper
All Responded
2018-0413 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator caseloads, causing delayed follow-ups and inadequate risk assessments.
Bradley Morgan
All Responded
2018-0412 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of timely patient follow-up, which created a risk to life.
Stephen Jackson
All Responded
2018-0416 4 Oct 2018 Birmingham and Solihull
Birmingham Clinical Commissioning Group NHS England
Concerns summary Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP referral, leaving the patient unsupported due to underfunding.
Terence Bennett
All Responded
2018-0282 14 Sep 2018 Wiltshire and Swindon
Avon and Wiltshire Mental Health NHS Tr…
Concerns summary Numerous systemic failures in mental health care include inadequate care plans, poor record-keeping, lack of family involvement, insufficient staff training and supervision, and an unsafe consultant rota.
Daniel Collins
Historic (No Identified Response)
2018-0283 14 Sep 2018 Birmingham and Solihull
Birmingham and Solihull Clinical Commis… Birmingham Women’s and Children’s NHS T…
Concerns summary A mental health service transferred a recently suicidal patient's care, requiring the patient to initiate contact with the new service, without proper handover or follow-up, risking loss of care during a crisis.
Kevin Sherwood
All Responded
2018-0289 11 Sep 2018 Hertfordshire
Network Rail
Concerns summary Insufficient railway boundary fencing, consisting only of post and wire, in an area frequented by walkers, creates a risk of trespass onto the train line.
Daniel O’Mahony
All Responded
2018-0258 30 Aug 2018 Hertfordshire
London North Western Railways
Concerns summary Inadequate railway anti-trespass measures, including missing gates, gaps in fencing, and unreviewed signage, increase access to railway lines and the risk of future deaths.
John Hill
All Responded
2018-0195 25 Jun 2018 Dorset
Dorset Police Home Office
Concerns summary Firearms licensing checks failed to include crucial enquiries with family members, missing vital information about the applicant's suicidal intentions before a certificate was granted.
Andrew Hanahoe
All Responded
2018-0184 19 Jun 2018 Bedfordshire & Luton
Network Rail
Concerns summary A railway foot crossing lacked adequate safety measures, including proper fencing, warning lights, or trespass deterrence, despite high-speed trains, posing a significant risk.
Karen Wiggins
Historic (No Identified Response)
2018-0177 13 Jun 2018 Wiltshire and Swindon
Swindon Borough Council
Concerns summary Multi-storey car parks in Swindon lack physical barriers or warning notices, despite previous suicidal falls, failing to prevent individuals from jumping.
George Dyson
All Responded
2018-0168 29 May 2018 West Yorkshire (West)
Calderdale Council
Concerns summary The urgent need to review and implement protective safety measures on North Bridge to prevent further fatalities, following previous similar incidents.
Grahame Searby
Historic (No Identified Response)
2018-0162 23 May 2018 West Yorkshire (West)
South West Yorkshire NHS Trust
Concerns summary The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
Mwitumwa Ngenda
Historic (No Identified Response)
2018-0167 20 May 2018 West Yorkshire (West)
Calderdale Council
Concerns summary Concerns focus on the urgent need for preventative measures and design changes on Scammonden Bridge to prevent future suicide attempts.
Stephen Tidey
All Responded
2018-0140 8 May 2018 Surrey
Surrey & Borders Partnership NHS Trust Surrey County Council Surrey Police
Concerns summary Inadequate recording of changes in suicide risk assessments and significant delays by mental health services in acting on high-risk MASH referrals following a critical trigger event.
Naseeb Chuhan
All Responded
2018-0099 9 Apr 2018 West Yorkshire (East)
Financial Conduct Authority
Concerns summary Payday loan companies contributed to the deceased's dependency by encouraging loans despite awareness, and their financial checks were inadequate.
Kellie Taylor
All Responded
2018-0083 19 Mar 2018 East Riding and Kingston upon Hull
Humber Bridge Board
Concerns summary The poor resolution of the CCTV system hindered accurate monitoring of individuals and delayed timely intervention during potential emergencies at the bridge.
Penelope Benton
All Responded
2017-0349 30 Nov 2017 Black Country
Dudley and Walsall Mental Health NHS Tr…
Concerns summary The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.