Recurring concern

Unreliable police handovers of safety-critical information

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First reported 27 Nov 2020•Latest report 23 Jan 2026

Definition

What this concern includes

Includes failures in police handover arrangements, including handover content, written records, guidance, training, transfer of responsibility, communication between officers or forces, and receipt or use of information about mental-health presentation, violence, threats, substance use, weapons or other material risks.

Not included

  • Excludes generic police record-keeping or communication failures where no police handover or transfer of safety-critical information is identified.
  • Excludes handovers between non-police organisations unless the assertion explicitly concerns the same police handover process.
  • Excludes failures to act after a complete and reliable police handover has been received.
  • Excludes clinical assessment, treatment or leave decisions where the police handover process itself was not deficient.
Reports
5

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2020–2026

First to latest report issue date

Stated actions
11

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

South Yorkshire Police3
Greater Manchester Police1
Metropolitan Police Service1
Midlands Partnership University NHS Foundation Trust1
Mitie1
National Police Chiefs’ Council1
NHS England1
Sussex Police1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Western)

    AI-generated summary

    Roger Gary Leadbeater · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roger Gary Leadbeater died on 9 August 2023 from multiple stab wounds inflicted by a patient detained under the Mental Health Act who had absconded from escorted leave. The report identified concerns about inadequate and poorly recorded handovers between police forces and the mental health trust, which meant significant risk information was not clearly communicated and may have affected decisions to grant leave. It also noted that, as of January 2026, relevant policies and auditing arrangements had not been updated to support the use of new handover forms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to audit use of police handover forms

    Wider context from the report

    “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died. The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation. On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use. I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave. ”

    Source location

    Roger Gary Leadbeater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to update policies supporting handover-form implementation

    Wider context from the report

    “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died. The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation. On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use. I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave. ”

    Source location

    Roger Gary Leadbeater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to appropriately communicate key information in police handovers for people detained under the Mental Health Act

    Wider context from the report

    “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died. The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation. On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use. I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave. ”

    Source location

    Roger Gary Leadbeater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to clearly record police handovers

    Wider context from the report

    “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died. The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation. On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use. I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave. ”

    Source location

    Roger Gary Leadbeater · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Run a monthly comparison of hospital-originating missing-person episodes against Form 1157 submissions to identify missing documentation.

    Verbatim wording from the response

    “The Missing Person Safeguarding Unit within the Public Protection Division will run a monthly report identifying all Missing Person episodes originating from hospitals. This will be shared with the Prevention Hub to compare against their 1157 submissions via the updated app, ensuring that the required documentation has been completed for every relevant incident.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 5 · response
    Published 29 January 2026

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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

    Amend Form 1157 and the supporting policy to mandate structured recording and handover of risk information across specified mental-health conveyances.

    Verbatim wording from the response

    “To address the issues that presented in Mr Leadbeater’s case, GMP has amended Form 1157 and moreover extended the circumstances in which the form is mandated for completion. The form must now be completed whenever officers take or convey (or assist in conveying) a person to hospital under any of the following circumstances:”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 2 · response
    Published 29 January 2026

    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

    Update, test and release the Form 1157 mobile app with the revised structure and mandatory risk-information fields.

    Verbatim wording from the response

    “To ensure the amended Form 1157 is fully embedded into frontline practice, GMP is also updating the digital version of the form used on officers’ mobile devices. An initial meeting to scope the required changes to the 1157 mobile app took place on 23rd February 2026, during which the technical and operational requirements were agreed. The final sign off for the project is due to take place on 16th March 2026 after which development work will begin. It is estimated that it will take 3 months for the completion of testing and for full release of the app to take place.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 4 · response
    Published 29 January 2026

    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

    Integrate case learning on risk identification, documentation and information sharing into Missing Person CPD and promoted-officer skills courses.

    Verbatim wording from the response

    “GMP is embedding the learning arising from this case into its wider professional development framework. The circumstances and lessons identified will be incorporated into Missing Person Continual Professional Development (CPD), ensuring that all officers receive consistent guidance on risk identification, documentation and effective information sharing.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 5 · response
    Published 29 January 2026

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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

    Produce and publish a mental-health missing-persons CPD video covering risk assessment, conveyance responsibilities and structured hospital handovers.

    Verbatim wording from the response

    “This learning will also be integrated into the Sergeants’, Inspectors’ and Superintendents’ Skills Courses delivered to all newly promoted officers. In addition, the Vulnerability CORE within the Public Protection Division is producing a short CPD training video focused on mental health considerations in Missing Person cases. The video will outline expectations around risk assessment, conveyance responsibilities, and the structured handover of pertinent risk information to receiving hospitals, including the completion of Form 1157.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 5 · response
    Published 29 January 2026

    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

    Require PRISM Care Plan triage staff to verify Form 1157 completion and attachment before closing relevant Care Plans.

    Verbatim wording from the response

    “In addition, completion of the 1157 has now been incorporated into the new PRISM app used by District Safeguarding Teams (MASH). Officers and staff triaging Care Plans must confirm that the Form 1157 has been completed and attached before a Care Plan can be closed. This creates a clear check-and-balance within the system and prevents closure where the correct safeguarding paperwork has not been provided.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 5 · response
    Published 29 January 2026

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Andrew Herrin Dodds · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Herrin Dodds was assessed and detained under section 136 after expressing suicidal thoughts and threatening to harm himself, but was later released and allowed to board a train. He took his own life on the train and was pronounced deceased at Tamworth train station. The principal concerns were failures to pass on next-of-kin and recent section 136 information, and missing information that might have prompted further contact with mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to pass relevant details, including next-of-kin information, to the s136 suite

    Wider context from the report

    “(1) Police did not pass over relevant details including next of kin to the s136 suite meaning next of kin could not be contacted. They also did not inform next of kin to contact the s136 directly and did not provide any further updates. This happened shortly after a shift change over so whether a full handover was provided between officers to allow this information to be given is not clear. ”

    Source location

    Andrew Herrin Dodds · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. West Sussex, Brighton and Hove

    AI-generated summary

    Miles Ethan Hurley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of formal written handovers of mental health presentation between police officers

    Wider context from the report

    “1. Lack of effective Communication between police officers The absence of a formal written handover between police officers regarding how an individual is presenting to be able to more accurately assess and appropriately direct assessment and care, particularly for first time offenders such as Miles who was not known to the police. Prior to and at the time of his arrest he was recognised by members of the public and the arresting police officers as showing significant signs of disturbance in his mental health with incongruent speech, inappropriate behavioural affect, and delusional beliefs such as thinking he was playing ‘Grand Theft Auto’ whilst driving recklessly, on a background of intoxication. The extent and the severity of his mental health difficulties was not adequately conveyed through standard ‘word of mouth’ communication between police officers, complicated by Mr Hurley appearing to be more contained and less obviously mentally unwell in custody. ”

    Source location

    Miles Ethan Hurley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    Maintain documented, verbally delivered and CCTV-recorded custody handovers, with live risk updates, shared access, audit trails, staff training and peer review.

    Verbatim wording from the response

    “At the point of handover, the Principal Sergeant will refer to a handover document (a copy of which is supplied at Appendix 1) from which they will brief the oncoming team verbally. All members of the current duty team and the oncoming team will be present. They are each given a copy of the handover document which they can refer to during the briefing. The briefing is delivered by the Principal Custody Sergeant in person and is recorded on CCTV which is accessible at any time.”

    Source location

    Response from Sussex Police
    Page 2 · response
    Published 29 July 2024

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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

    Consider best practice through the Betterment Workstream, including a nationally recognised pre-arrival risk assessment for communicating custody risks.

    Verbatim wording from the response

    “The practice of arresting officers risk assessments being formally completed prior to arrival at custody is inconsistent across forces. Best practice is being considered through the NPCC Betterment Workstream to include a nationally recognised pre arrival risk assessment in place to communicate risks and concerns that may have been raised.”

    Source location

    Response from NPCC
    Page 1 · response
    Published 29 July 2024

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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

    The communication issue is a local force matter and outside the NPCC’s remit for comment.

    Verbatim wording from the response

    “a) This is a local force issue and therefore not for the NPCC to make comment.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 29 July 2024

    Open published response

  4. South Yorkshire (Western)

    AI-generated summary

    Matthew Terrill · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of mandatory or refresher training on information handover during detainee booking

    Wider context from the report

    “5. Lack of refresher or mandatory annual training for police officers in relation to information to be passed to the custody officers during the booking in procedure. I am told that there is no specific mandatory training for police officers on the information expected of them at the custody suite desk during the booking in procedure, but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I am concerned that police officers are regularly handing over to custody officers without any mandatory training or refresher training on the subject, which leaves the information that they decide to pass over open to discretion. Training an officer once, at the beginning of their career, leaves the door open to the development of bad practice and the fallibility of human memory. This gives rise to a risk of future death for detained persons if pertinent information is omitted, for example health or intoxication information. ”

    Source location

    Matthew Terrill · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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 the booking-in sheet and create holding-area posters reminding officers to report illness, injuries and intoxication to the Custody Sergeant.

    Verbatim wording from the response

    “Future work”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 8 · response
    Published 4 April 2024

    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

    Design force screen savers and deliver annual local CPD reinforcing information, roles and responsibilities when booking detainees into custody.

    Verbatim wording from the response

    “Force screen savers will be designed by the Custody Lead, incorporating key and additional information they must provide to a Custody Sergeant when booking in a detained person into custody, this will be supported by a yearly CPD package and delivered locally by Force Inspectors/Detective Inspectors again reminding officers around their role and responsibilities.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 8 · response
    Published 4 April 2024

    Open published response

  5. Inner North London

    AI-generated summary

    Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to pass relevant incident and vulnerability information to ambulance and hospital staff

    Wider context from the report

    “The police officer did not pass on this crucial account to the emergency ambulance crew who transported Ms Marchessou to hospital, nor to any of the doctors or nurses at the hospital. 2. Ms Marchessou told the police officers that she had blacked out and could not remember what had happened, then that she thought she had stepped into the road as the result of a panic attack. She also said that she had stepped in front of the bus because she was upset about being denied contact with her children. The police officers did not pass on the crucial information that Ms Marchessou said she had stepped in front of the bus because she was upset about being denied contact with her children, either to the emergency ambulance crew or to the treating doctors or nurses. ”

    Source location

    Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    Improve officers’ sharing of vital incident information with colleagues, ambulance crews and medical staff.

    Verbatim wording from the response

    “Officer 1 interviewed the bus driver at the scene of the collision whilst Officer 2 dealt with Ms Marchessou in the ambulance. This would be normal practice where two parties were involved, with each officer initially dealing with their casualty, witness or other party involved. The senior officer has discussed this incident in detail with Officer 1, providing him with the opportunity to reflect on the decisions he made. It was evident from their discussion that the officer was reflective as he recognised that he would deal with a similar incident differently next time. He would now relay the bus driver’s account to his colleague who was dealing with Ms Marchessou at the scene and subsequently provide this information to the medical staff at the scene and at the hospital.”

    Source location

    2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
    Page 2 · response
    Published 30 December 2020

    Open published response
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Data last updated 7 September 2026