PFD report

Benn Curran-Nicholls · Prevention of Future Deaths report

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Issued 27 Nov 2023•Manchester City

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Report evidence summary

Concerns raised1

  1. Risk of deaths arising in similar circumstances
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Review advice and complete a full risk assessment concerning public messaging about yew-tree ingestion.

    Stated by UK Health Security AgencyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  2. Action

    Highlight the yew-tree ingestion risk to UKHSA’s other English regions and the Devolved Administrations.

    Stated by UK Health Security AgencyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.
  3. Action

    Brief all 24 North West Directors of Public Health on yew-tree ingestion risks, request consideration of local action, and share relevant public resources.

    Stated by UK Health Security AgencyStated completedThe respondent said that this action was complete when they made their response on 1 December 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    UKHSA considers public messaging about ingesting plants or yew inappropriate because the issue is rare, lacks clear public actions, and could cause unintended harm.

    Stated by UK Health Security AgencyNo action considered necessaryThe respondent said that no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Risk of deaths arising in similar circumstances

Wider context from the report

“There is a risk of a death arising in similar circumstances, and informing the public will clearly reduce the risk of those deaths. Perhaps particularly so for a child whose carer would be so informed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review advice and complete a full risk assessment concerning public messaging about yew-tree ingestion.

Verbatim wording from the response

“Council contacted UKHSA on 26 September 2023 requesting UKHSA to consider any messaging alongside Environmental Health and Public Health Colleagues in the Council. UKHSA public health specialist and environmental public health scientists and Manchester City Council Public Health and environmental health colleagues undertook a full risk assessment on 27 September 2023, and followed up with an email on the same date summarising the agreed position. The decision not to issue public health messaging was a joint decision between UKHSA and Manchester City Council and was made following wider discussions with key specialists between the two agencies.”

Source location

Response from UKHSA
Page 2 · response
Published 1 December 2023

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Highlight the yew-tree ingestion risk to UKHSA’s other English regions and the Devolved Administrations.

Verbatim wording from the response

“In addition to revisiting the advice and risk assessment referred to above, UKHSA have highlighted the risk of ingesting yew tree berries across its partner agencies as follows:”

Source location

Response from UKHSA
Page 3 · response
Published 1 December 2023

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Brief all 24 North West Directors of Public Health on yew-tree ingestion risks, request consideration of local action, and share relevant public resources.

Verbatim wording from the response

“In addition to revisiting the advice and risk assessment referred to above, UKHSA have highlighted the risk of ingesting yew tree berries across its partner agencies as follows:”

Source location

Response from UKHSA
Page 3 · response
Published 1 December 2023

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

UKHSA considers public messaging about ingesting plants or yew inappropriate because the issue is rare, lacks clear public actions, and could cause unintended harm.

Verbatim wording from the response

“As per our previous advice provided to the Council, we maintain that there is a greater risk of doing harm than good by proactively sharing messaging with the general public to not ingest plants, or specifically yew tree, as there is a risk of unintended consequences from such messages, where it highlights the risk of harm which may in turn provide a source for people to self-harm as a potential route for suicide.”

Source location

Response from UKHSA
Page 2 · response
Published 1 December 2023

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

UKHSA disputes that the decision not to issue yew-poisoning messages was insufficiently considered, stating it was proportionate to assessed risks and messaging impacts.

Verbatim wording from the response

“Council contacted UKHSA on 26 September 2023 requesting UKHSA to consider any messaging alongside Environmental Health and Public Health Colleagues in the Council. UKHSA public health specialist and environmental public health scientists and Manchester City Council Public Health and environmental health colleagues undertook a full risk assessment on 27 September 2023, and followed up with an email on the same date summarising the agreed position. The decision not to issue public health messaging was a joint decision between UKHSA and Manchester City Council and was made following wider discussions with key specialists between the two agencies.”

Source location

Response from UKHSA
Page 2 · response
Published 1 December 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Matter Two is assigned to Manchester City Council and is not addressed by UKHSA.

    Stated by UK Health Security AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Matter Two is assigned to Manchester City Council and is not addressed by UKHSA.

Verbatim wording from the response

“The concerns raised in the report have been considered and reflected upon by UKHSA and its response is below. UKHSA notes that two matters of concern were raised in the Regulation 28 report. This response addresses “Matter One” only, as “Matter Two” is for Manchester City Council.”

Source location

Response from UKHSA
Page 1 · response
Published 1 December 2023

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
1/2

Data last updated 7 September 2026