Insights

Themes, trends, and accountability across 6,263 PFD reports

PFD Themes

1,000 theme links across the PFD corpus, organised into 8 pillars.

Clinical care & patient safety

Medication, falls, infection control, premature discharge, equipment, training, and records failures in healthcare settings.

Record-keeping failures68Training deficiencies41Falls prevention14Medication errors13+3 more

Workforce & NHS pressures

Staffing shortages, resource constraints, and poor coordination between providers.

Coordination of care64Staffing shortages25NHS resource pressures8

Mental health & substance misuse

Mental health crisis response, suicide prevention, and substance-related deaths.

Mental health crisis response30Suicide prevention28Substance misuse7

Vulnerable populations

Deaths involving children, care-home residents, people experiencing homelessness, and domestic-abuse victims.

Care home failings17Child safeguarding14Homelessness1Domestic abuse

Detention & use of force

Deaths in prison, police custody, immigration detention, and cases involving restraint.

Prison and custody9Restraint and use of force3

Emergency response

Ambulance, fire, police response delays and communication failures between emergency services.

Communication failures82Emergency response delays26

Environment, infrastructure & products

Road-safety, workplace-safety, and defective-product deaths.

Road safety12Workplace safety5Product safety4

Wheelchair accessible vehicle safety standards and equipment compatibility verification procedures

Other & emergent

292

Catch-all pillar for themes that have not yet been assigned to a pillar, including newly AI-extracted themes.

Systemic investigation and learning failures in healthcare governance73Care coordination gaps in mental health discharge planning69Patient assessment and clinical escalation protocols in emergency dispatch43Clinical decision-making and protocol compliance in acute care assessment and escalation24+297 more

PFD Heatmap

6,259 reports plotted across 350 coroner areas. Deep link: /map

Legend — Dominant Category per Area

Hospital

Road

Alcohol

State Custody

Other

drug

Care Home

Emergency services

Community health

Mental

Child

Suicide

Workplace

Fill opacity represents PFD volume for that coroner area (logarithmic scale). Click any region to see its name and PFD count. Scroll, pinch, or use the +/− controls to zoom; drag to pan. Scotland and Northern Ireland have separate coroner systems and are shown in outline only.