Suicide
PFD Category
Reports: 841
Areas: 72
Earliest: Feb 2015
Latest: 12 Mar 2026
83% response rate (above 62% average). 55% of classified responses show concrete action taken. Reports rose 26% from 117 (2023) to 148 (2024).
PFD Reports
614 resultsRobert Smith
All Responded
2025-0240
21 May 2025
South Wales Central
Cardiff & Vale University Health Board
Concerns summary
Mental health services lack clear guidance for clinicians on family information sharing and gathering, leading to inconsistent practices. Patient information leaflets also fail to adequately explain these processes.
Action taken summary
The Health Board has co-produced values-based guidance with families on information sharing and gathering, which will be finalized. They commit to reviewing and updating the patient information leafle
Wayne Brown
All Responded
2025-0235
20 May 2025
Birmingham and Solihull
West Midlands Fire Service
Concerns summary
The fire service lacked policy for investigating work-related suicides and provided inadequate mental health support for senior staff, failing to record welfare concerns during investigations.
Action taken summary
West Midlands Fire Service disputes the coroner's finding that no investigation was undertaken, stating they sought external legal advice and assessment of evidence. They will develop a new policy for
Joseph Powell
All Responded
2025-0234
17 May 2025
Cheshire
Royal College of General Practitioners …
Concerns summary
GPs failing to proactively book follow-up appointments for mental health patients, instead requiring them to self-book, often results in missed care and medication for vulnerable individuals.
Action taken summary
The RCGP will highlight this case to its Mental Health Special Interest Group to promote safety planning in suicide prevention and consider GP booking of follow-up appointments as part of a safety pla
Margaret Reeves
All Responded
2025-0227
13 May 2025
West Sussex, Brighton and Hove
Sussex Partnership NHS Foundation Trust
NHS Sussex
Concerns summary
Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
Action taken summary
The Trust plans to migrate to the SystmOne Electronic Patient Record system by November 2025 to enable two-way, real-time information sharing with GP surgeries. They are also prioritizing the rollout
James Sheppard
All Responded
2025-0229
8 May 2025
Gloucestershire
Gloucestershire Health & Care NHS Found…
Department of Health and Social Care
Concerns summary
There is an insufficient number of psychiatric unit beds available to meet patient demand, posing a risk to those requiring mental health care.
Action taken summary
The Trust has already undertaken significant work to improve bed management efficiency, reducing Out of Area Placements. They are also focused on reducing the average length of stay and are developing
Sarah Boyle
All Responded
2025-0211
2 May 2025
Cheshire
Ministry of Justice
HMPPS
Concerns summary
The ACCT process at HMP Styal is ineffective for preventing self-harm, lacking therapeutic mental health input. The prison holds many complex patients requiring hospital-level care, with slow transfer processes, risking future deaths.
Action taken summary
HMPPS has provided national safety team support to HMP Styal, delivering a local safety summit and upskilling staff on self-harm and suicide risk awareness. The Governor and healthcare provider will a
Jacqueline Potter
All Responded
2025-0200
24 Apr 2025
Somerset
Royal College of Obstetricians and Gyna…
Somerset Foundation Trust
National Institute for Health and Care …
+2 more
Concerns summary
Families of psychiatric patients on leave are not provided with codified risk and safety plans. Furthermore, secure unit Wi-Fi lacks filters, allowing vulnerable patients access to self-harm websites, increasing suicide risk.
Action taken summary
NHS England has implemented several initiatives to improve menopause care, including launching a Women’s Health Strategy, appointing a National Menopause Clinical Champion, investing in women’s health
Linda Sitch
All Responded
2025-0201
17 Apr 2025
Essex
Essex County Council
Concerns summary
Adult Safeguarding (ASC) failed to act on urgent referrals due to "human error" and inappropriate managerial downgrading of priority cases. ASC lacks robust oversight and auditing to prevent such systemic failures, risking future harm.
Action taken summary
Essex County Council has implemented transformative changes to its Central Safeguarding Triage Team, resulting in 96% of alerts being triaged within 72 hours. They have also reviewed and implemented n
Jonathan Hamer
All Responded
2025-0184
10 Apr 2025
West London
South West London and St George’s Hospi…
Concerns summary
Gaps in community mental health care due to staff absences and issues with supported housing transitions contributed to a patient's deteriorating condition and subsequent death by suicide.
Action taken summary
The Trust has implemented a new communication protocol, revised patient contact information, and introduced an 'out of office' email response system. They have also revised their handover policy, upda
Christopher McDonald
All Responded
2025-0172
7 Apr 2025
South London
South London and Maudsley NHS Foundatio…
Concerns summary
Psychiatric unit staff lacked understanding and adherence to the 'AWOL - Missing & Absent Persons Policy,' failing in individualized assessments, police accompaniment, and joint action planning.
Action taken summary
The Trust has updated its AWOL Policy to mandate MDT risk assessments, implemented bespoke refresher training for staff on the National Psychosis Unit, and reinforced requirements for staff accompanim
Imogen Nunn
All Responded
2025-0156
24 Mar 2025
West Sussex, Brighton and Hove
Department of Health and Social Care
National Register of Communication Prof…
NHS England
Concerns summary
A severe shortage of British Sign Language interpreters is hindering urgent mental health crisis assessments and delaying judicial proceedings for deaf patients and witnesses.
Action taken summary
NHS England highlights that a national framework agreement for interpretation services is in place and a National Working Group for BSL/Deaf Mental Health Services has been established and met. They a
Sheridan Pickett
All Responded
2025-0150
19 Mar 2025
Manchester South
Department of Health and Social Care
Concerns summary
No specific coroner's concerns regarding systemic issues or risks to prevent future deaths were identified in the provided text.
Action taken summary
The Department of Health and Social Care disputes the coroner's concerns regarding a lack of clear guidelines for online prescribing and information sharing, citing existing guidance and regulatory fr
Darren Turner
All Responded
2025-0144
17 Mar 2025
Essex
Essex Partnership University NHS Founda…
Concerns summary
Multiple serious failures in care, management, and treatment provided by the Essex Partnership NHS Foundation Trust amounted to neglect, contributing to the deceased taking his own life.
Action taken summary
Essex Partnership University NHS Foundation Trust has implemented a new discharge policy (Dec 2024), secured additional inpatient staff funding, and ensured daily comprehensive note completion. A new
Rhiannon Williams
All Responded
2025-0139
12 Mar 2025
SWANSEA & NEATH PORT TALBOT
Innovation and Technology
Department for Science
OFCOM
Concerns summary
Online suicide forums and social media platforms provided information on self-harm and misleading professionals, raising concerns about the adequacy of The Online Safety Act 2023 in preventing access to such harmful content.
Action taken summary
The Department outlines the existing Online Safety Act framework and Ofcom's role in enforcement, noting Ofcom's investigation into a suicide forum. DSIT officials continue to work with DHSC on the Su
Sean Higgins
All Responded
2025-0133
11 Mar 2025
Mid Kent and Medway
HMP Rochester
Concerns summary
Officers chairing ACCT reviews at HMP Rochester failed to read all relevant documentation, leading to inaccurate risk assessments, and some did not understand how to properly complete support plan paperwork.
Action taken summary
HMP Rochester has produced and shared a training video for case coordinators and their managers on ACCT reviews and support plans. The Safety Team has also conducted briefing sessions with all case co
Jean Pike
All Responded
2025-0127
7 Mar 2025
SWANSEA & NEATH PORT TALBOT
Swansea Bay University Health Board
Concerns summary
Discharge decisions were made without essential multi-disciplinary meetings or consulting care coordinators, despite clear warnings of high suicide risk, indicating a systemic failure in communication and risk management.
Action taken summary
Swansea Bay University Health Board has approved and implemented new Standard Operating Procedures for discharge planning requiring mandatory multi-disciplinary team discussions, including the care co
Henok Gebrsslasie
All Responded
2025-0124
6 Mar 2025
Coventry
Coventry and Warwickshire Partnership N…
Concerns summary
Despite a known risk of ligature points on patient bedroom doors and identification of door top alarms as a solution, these crucial safety measures have not been implemented in a psychiatric unit for over 42 months.
Action taken summary
Coventry and Warwickshire Partnership NHS Trust has implemented several safety improvements, including reducing ligature points and fitting door top alarms in all acute inpatient wards. They have also
Andrea Mann
All Responded
2025-0130
6 Mar 2025
West Yorkshire Western
Bradford District Care NHS Trust
Action taken summary
Bradford District Care NHS Trust has implemented a new re-referral process and a digital referral/screening platform, and embedded psychiatrists and psychologists within community mental health teams.
Alfie Lawless
All Responded
2025-0118
4 Mar 2025
Manchester South
Greater Manchester Police
Concerns summary
Greater Manchester Police significantly delayed classifying a death as a "Death or Serious Injury" incident, raising concerns about the quality of their internal review and learning from incidents.
Action taken summary
Greater Manchester Police's Professional Standards Directorate has designed a new form for assessing Death or Serious Injury (DSI) incidents to improve rationale and identify learning opportunities. T
Amy Padley
All Responded
2025-0105
24 Feb 2025
SWANSEA & NEATH PORT TALBOT
SWANSEA BAY UNIVERSITY HEALTH BOARD
Concerns summary
Mental health services prioritize addiction treatment over mental health support, lack guidance for staff on managing co-occurring conditions, and are reluctant to offer simultaneous support for addiction and mental health.
Action taken summary
Swansea Bay University Health Board has completed the development of a comprehensive Standard Operating Procedure (SOP) and Care Pathway for individuals with co-occurring mental health and substance u
Isaiah Olugosi
All Responded
2025-0106
24 Feb 2025
West London
HMP Wormwood Scrubs
Concerns summary
A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.
Action taken summary
HMPPS has addressed issues with the prison's phone lines, ensuring they are always contactable and regularly tested. Regarding the intercom system, they state it was not designed for external contact
Hayley Beavington
All Responded
2025-0097
20 Feb 2025
Inner North London
North London NHS Foundation Trust
Concerns summary
A crisis house wrongly denied admission to a high-risk suicidal patient due to restrictive criteria. The consultant failed to guide the junior doctor on challenging this decision, leading to premature discharge and the patient's death.
Action taken summary
The Trust has implemented an updated Crisis Hub Operational Policy and Standard Practice for Community Teams (both 2025) to ensure referrals are not declined without formal escalation and risk review,
Duncan Holloway
All Responded
2025-0102
20 Feb 2025
Inner North London
North London NHS Foundation Trust
British Association for Counselling and…
Concerns summary
Psychotherapy lacked minimum standards for note-keeping and training in suicidality management or emergency police contact. There were also concerns about uncoordinated care between different agencies.
Action taken summary
The BACP clarifies that its Ethical Framework requires accurate record-keeping, but a client can request no notes. They state that accredited members are trained to support clients with suicidal ideat
Zahra Mohamed
All Responded
2025-0098
18 Feb 2025
Inner North London
Ministry of Justice
Metropolitan Police
Concerns summary
Significant 2-week delays in obtaining and executing Mental Health Act warrants persist due to court and police scheduling issues, increasing the risk of harm to vulnerable patients.
Action taken summary
The Metropolitan Police Service states that its corporate process for s.135 warrants is currently under review, and learning identified from the PFD report will be incorporated. They also clarified ex
Ronald Bainborough
All Responded
2025-0099
18 Feb 2025
Inner North London
Metropolitan Police
Ministry of Justice
Concerns summary
Protracted 20-day timescales for obtaining and executing Mental Health Act warrants, due to limited court availability and police delays, expose individuals to significant harm before assessment.
Action taken summary
The Metropolitan Police Service is currently reviewing its corporate process for s135 warrants and will incorporate the matters raised in the PFD report and identified learning into this review. HMCTS