Suicide

PFD Category
Reports: 845 Areas: 72 Earliest: Feb 2015 Latest: 24 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 696 No Response 13 Historic 112 Pending 18
AI Classification
Action Taken 56%
Action Planned 23%
Noted 14%
Disputed 7%
Based on 893 classified responses
Reports by Quarter
PFD Reports
845 results
Kimberley Parsons
All Responded
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.
Malcolm Burge
Historic (No Identified Response)
2015-0072 27 Feb 2015 Somerset (West)
Newham Council
Concerns summary Council debt recovery procedures failed to accommodate a vulnerable individual's age, mental awareness, and inability to use modern communication methods, contributing significantly to his tragic death.
Isobel Griffin and Jane Clark
Historic (No Identified Response)
2015-0049 12 Feb 2015 Northamptonshire
Northamptonshire NHS Partnership Trust …
Concerns summary Critical failures in risk assessment, handover, and documentation were evident, with staff not reading notes, inadequate patient monitoring, and non-ligature-proof ward doors contributing to self-harm risks.
James Taylor
All Responded
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
All Responded
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
Samantha Gould and Christine Gould
All Responded
2021-0184 Cambridgeshire and Peterborough
Concerns summary Police lacked follow-up with clinicians/parents and failed to inform mentally ill child abuse victims about their option to provide evidence later. There was no guidance for police on communicating with such vulnerable minors.
Action taken summary Cambridgeshire County Council has launched the 'Strong Families Strong Communities' strategy (March 2021) and the 'YOUnited' partnership (July 2021) to enhance emotional health and wellbeing support f
Alan Griffin
All Responded
2021-0243 Inner North London
Concerns summary Catholic safeguarding failed to adequately scrutinise allegations, delayed providing Father Griffin with details, and offered insufficient pastoral support. Significant delays in the safeguarding investigation were also identified.
Action taken summary The Church of England has formed a Case Steering Group to oversee its response and next steps. It is committed to undertaking a Lessons Learned Review and implementing a comprehensive action plan to i
Dean Crossman
Response Pending
2022-0157 Teesside and Hartlepool
NHS England NHS Tees Valley Clinical Commissioning …
Concerns summary Persistent national issues with out-of-hours access to s.12 doctors and timely ambulance transport delay Mental Health Act assessments and patient transfers, increasing risk.
Action taken summary NHS England has provided funding to Local Authorities to support Mental Health Act assessments, commissioned research on best practice models, and updated Ambulance Quality Indicators (effective Oct 2
Louise Allen
All Responded
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
All Responded
2022-0163 South Wales Central
Powys Teaching Health Board Powys County Council
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
All Responded
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
Mena Terefi
Response Pending
2022-0166 West London
NHS England West London Mental Health NHS Trust
Concerns summary Mental health services face demand far exceeding capacity following a transformation, with referrals over 100% above anticipated levels and insufficient resources, risking future deaths.
Kate Hyatt
All Responded
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
All Responded
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
Zsolt Kirjak
Response Pending
2022-0197 Inner West London
Central and North West London NHS Found… Imperial College health Care NHS Trust … Portland Practice
Concerns summary The patient received an incomplete psychiatric and risk assessment that failed to appraise his serious suicide risk factors and previous self-harm attempts. His wife was not given opportunity to contribute to assessments.
Shona Campbell
Response Pending
2022-0202 Manchester City
Safety Matters Ltd Greater Manchester Mental Health NHS Fo… Alternative Futures Group +1 more
Concerns summary Deficient record keeping, incomplete patient observations, and inadequate staff communication regarding self-harm risks were identified. Patients also had access to ligatures, and risk assessments were not properly updated.
Dominic Noble
All Responded
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
All Responded
2022-0356 Avon
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
All Responded
2025-0615 Derby and Derbyshire
Derbyshire Community Health Services NH… Sett Valley Medical Centre NHS England +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
Darren Mindham
Response Pending
2016-wp25374 London (South)
Advisory Council on the Misuse of Drugs