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
Sidi Bojang
All Responded
2025-0436 1 Aug 2025 North London
Department of Health and Social Care
Concerns summary Patients exhibiting recent self-harm or suicidal thoughts were discharged by a senior psychiatric nurse without a psychiatrist review, despite significant changes in presentation, posing a risk of unsafe discharges.
Action taken summary NHS England has strengthened 24/7 mental health liaison services in all Type 1 Emergency Departments and published the Men's Health Strategy. They are also working towards consultant-led assessments a
Samantha Young
All Responded
2025-0375 25 Jul 2025 Hampshire, Portsmouth and Southampton
Department of Health and Social Care Hampshire and Isle of Wight Healthcare …
Concerns summary A lack of training for staff, especially agency staff, in mental health risk assessments, and persistent failure to engage and communicate with patients' families, compromise patient safety.
Action taken summary Hampshire and Isle of Wight Healthcare NHS Foundation Trust has remedied a data capture issue related to carer information and is designing a new risk assessment training programme for all staff, incl
Michael Pugh
All Responded
2025-0378 25 Jul 2025 Kent and Medway
His Majesty’s Prison and Probation Serv…
Concerns summary Inadequate ACCT process training for new prison officers led to an incomplete understanding of observation requirements, including inconsistent timing and recording for vulnerable prisoners.
Action taken summary HM Prison and Probation Service states that existing POELT and local induction training covers ACCT processes. Going forward, HMP Swaleside will promote its online Safety Learning Reference Library, i
Leia Sampson-Grimbly
All Responded
2025-0381 25 Jul 2025 North London
Department of Health and Social Care Tavistock and Portman NHS Foundation Tr…
Concerns summary Long waiting lists for first appointments at Gender Dysphoria clinics pose a significant risk, delaying crucial care for vulnerable individuals.
Action taken summary The Trust noted the concern about long waiting lists for Gender Dysphoria clinics, explaining that NHS England has been unable to commission sufficient capacity due to a lack of specialist staff and i
Isaac Ingle-Gillis
All Responded
2025-0373 22 Jul 2025 Gwent
Aneurin Bevan University Health Board
Concerns summary The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.
Action taken summary The Health Board has commenced work to broaden secondary care practitioners' access to the summary GP record via the Welsh Clinical Portal, including for the Crisis Resolution and Home Treatment Team.
Jairus Earl
All Responded
2025-0349 10 Jul 2025 Dorset
Department of Health and Social Care Home Office
Concerns summary Significant gaps in shotgun licence regulation, including no requirement to declare multiple properties or movement, and less stringent application criteria compared to firearms, create a risk of future deaths.
Action taken summary The NPCC commenced an additional two-day course in June 2025 for Firearms Licensing Enquiry Officers, focusing on domestic abuse, family turmoil, mental health, and wellbeing. They also clarified the
Andrew Kenward
All Responded
2025-0346 9 Jul 2025 Surrey
Department of Health and Social Care Home Office
Concerns summary There is no central monitoring for sodium nitrite poisoning, and high-purity sodium nitrite can be easily imported and purchased in lethal quantities without regulation or consideration for dilution, posing significant risk.
Action taken summary The Home Office is researching the availability of sodium nitrite and collaborating with DHSC on legislative options. Border Force issued guidance last year on controlling items intended to assist sui
John Kirkman
All Responded
2025-0344 8 Jul 2025 Kingston Upon Hull and the County of the East Riding of Yorkshire
NHS England
Concerns summary Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.
Action taken summary NHS England highlights existing systems like the National Care Records Service (NCRS), Summary Care Record (SCR), and National Record Locator (NRL) that improve data sharing. They are also developing
Sarah Lewis
All Responded
2025-0337 7 Jul 2025 Avon
Department of Health and Social Care
Concerns summary Inconsistent and under-resourced ME services, coupled with a lack of professional understanding and research, hinder diagnosis, validation, and appropriate support for sufferers.
Action taken summary NICE clarifies that the provision of ME/CFS services and professional education is primarily the remit of NHS England and other bodies. They highlight that NICE has already supported e-learning materi
Daniel Hatchett
All Responded
2025-0334 4 Jul 2025 East London
Queen Mary’s University of London Department of Health & Social Care
Concerns summary GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Action taken summary The Department of Health and Social Care highlights existing NHS Talking Therapies for long-term conditions and a men's health strategy in development. Mr Hatchett's general practice will now signpost
Jody Robb
All Responded
2025-0330 1 Jul 2025 County Durham and Darlington
Network Rail
Concerns summary Inadequate physical barriers and non-deterrent design allowed track access, compounded by train crews failing to report a person on the tracks despite multiple trains passing, hindering intervention.
Action taken summary Network Rail has submitted planning consent for further anti-suicide measures at Durham Station, including increasing the height of the parapet with an inward-curving safety barrier, with works hoped
Callan Atkins
No Identified Response
2025-0323 26 Jun 2025 Gloucestershire
Gloucestershire Health and Care NHS Fou…
Concerns summary Mental health crisis team capacity directly impacts same-day assessments, and the Trust does not secure additional resources when local teams lack capacity, risking timely patient care.
Louise Crane
All Responded
2025-0317 23 Jun 2025 Inner North London
North London NHS Foundation Trust
Concerns summary Inaccurate record-keeping, a widespread lack of therapeutic engagement understanding among staff, and systemic failures during step-down from PICU hindered safe patient transition and risk mitigation.
Action taken summary The Trust has introduced a mandatory policy on patient record keeping, delivered "Effective Record Keeping" training, and implemented a bi-monthly audit schedule showing improved compliance. They are
Louise Crane
All Responded
2025-0318 23 Jun 2025 Inner North London
NHS England Department of Health and Social Care
Concerns summary A significant safety concern is the absence of a nationwide policy or consistent approach to anti-ligature measures within mental health facilities.
Action taken summary NHS England disputes the concern, stating it has already adopted a comprehensive, nationwide approach to anti-ligature measures. This includes a National Patient Safety Alert issued in March 2020, Hea
Patrick Viles
All Responded
2025-0313 20 Jun 2025 Inner North London
Complex Spine Clinic
Concerns summary A doctor prescribed medication to a patient with known suicidal ideation shortly after a psychologist recommended urgent psychiatric input, raising concerns about medication safety.
Action taken summary The Complex Spine Clinic clarified that the consultant did not generate any prescriptions for Mr Viles after receiving a letter on 07/07/2024 from his psychologist indicating a potential risk of suici
Sally Burr
All Responded
2025-0297 13 Jun 2025 West Sussex, Brighton and Hove
NHS England
Concerns summary Detained mental health patients can exploit mobile internet access to research self-harm methods, as staff lack effective technical means to monitor or control usage, despite revised policies.
Action taken summary NHS England has published national 'Principles for using digital technologies in mental health inpatient treatment and care' (February 2025) and ensures all PFD reports are discussed by its Regulation
Andrew Connolly
All Responded
2025-0290 10 Jun 2025 Manchester South
Greater Manchester Integrated Care Board
Concerns summary GPs' reliance on telephone appointments for mental health assessments and lack of family input led to unrecognized patient risks due to absent guidance for these situations.
Action taken summary NHS Greater Manchester Integrated Care will produce and distribute an advice briefing for GPs reminding them of responsibilities for mental health patients, appropriate appointment modes, and family i
Cain Donald
All Responded
2025-0278 5 Jun 2025 Oxfordshire
Oxford Health NHS Foundation Trust
Concerns summary Deficiencies in discharge planning from a psychiatric unit, including inadequate engagement with family and probation, and a failure to supervise post-discharge medication compliance, contributed to mental health deterioration.
Action taken summary Oxford Health NHS Foundation Trust has implemented several changes, including mandatory training for CRHTT staff on family involvement in care planning and revising the 7-Day MDT process. They have al
Nicholas Gray
All Responded
2025-0283 5 Jun 2025 Essex
Essex Partnership University NHS Trust
Concerns summary The Trust's PSIRF Decision Monitoring Tool contained inaccurate and incomplete information regarding patient contact and self-harm, undermining potential investigation requirements.
Action taken summary Essex Partnership University NHS Trust has already amended its PSIRF Decision Monitoring Tool template, which came into use in January 2024. They have also implemented a more robust governance process
Pellumb Olaj
All Responded
2025-0277 3 Jun 2025 Inner North London
Islington Council
Concerns summary The council failed to consider a patient's history of paranoid schizophrenia and past suicide attempts by jumping from high places when housing him on the sixth floor.
Action taken summary Islington Council disputes the coroner's premise, stating their existing Housing Needs Assessment process in 2020 *did* consider Mr Olaj's mental health and was sufficient. They note the deceased decl
Callum Hargreaves
All Responded
2025-0262 29 May 2025 Cornwall and Isles of Scilly
NHS Cornwall and Isles of Scilly ICB
Concerns summary The rationale for not admitting a patient with complex PTSD/EUPD was unrecorded. Clinicians failed to explore or challenge his refusal to inform his mother about discharge, contrary to GMC guidance.
Action taken summary The Trust acknowledges the importance of family engagement and states inpatient services have already improved information provided to carers at admission. It clarifies that challenging a patient's de
Callum Hargreaves
All Responded
2025-0263 29 May 2025 Cornwall and Isles of Scilly
Cornwall Council
Concerns summary The rationale for not detaining a patient was unrecorded. Clinicians failed to adequately test or challenge his decision to withhold discharge information from his mother, and record-keeping was deficient.
Action taken summary Cornwall Council Care and Wellbeing has incorporated Mental Health Act assessments into its audit programme to improve documentation quality. It has also developed and disseminated guidance for Approv
Dean Bradley
All Responded
2025-0248 28 May 2025 Teesside and Hartlepool
Department of Health and Social Care Tees, Esk and Wear Valleys NHS Foundati… Integrated Care Board (NHS North East a… +4 more
Concerns summary Current resources for safeguarding intoxicated individuals with mental health illnesses are insufficient, as assessments cannot occur until sobriety, leaving vulnerable people at risk.
Action taken summary Stockton on Tees Council clarified that Police Officers could have detained Mr Bradley under Section 136 of the Mental Health Act and taken him to the Roseberry Park assessment suite, which is designa
Callum Hargreaves
All Responded
2025-0259 28 May 2025 Cornwall and Isles of Scilly
Ministry for Housing Communities and Lo…
Concerns summary A severe shortage of available housing in Cornwall, with high demand and low supply, contributed to the deceased's homelessness and exacerbated his mental health issues.
Action taken summary MHCLG highlights significant investment in affordable homes and over £1.2 billion provided through the Homelessness Prevention Grant since 2018. The government is also introducing a new offence in the
Callum Hargreaves
All Responded
2025-0260 28 May 2025 Cornwall and Isles of Scilly
Sanctuary Housing
Concerns summary Sanctuary Housing failed to properly investigate cuckooing and property damage for a vulnerable tenant, leading to an eviction notice instead of support, and lacked a clear policy for such situations.
Action taken summary Sanctuary Housing is committed to an internal review of its multi-agency approach to anti-social behaviour (ASB) and cuckooing, and will benchmark its policies against other social housing providers.