Concerns raised 4
Failure to audit use of police handover forms View source Failure to update policies supporting handover-form implementation View source Failure to appropriately communicate key information in police handovers for people detained under the Mental Health Act View source
Failure to clearly record police handovers View source See 1 more concern
Linked response
Greater Manchester Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Greater Manchester Police
Run a monthly comparison of hospital-originating missing-person episodes against Form 1157 submissions to identify missing documentation.
View source
Greater Manchester Police
Amend Form 1157 and the supporting policy to mandate structured recording and handover of risk information across specified mental-health conveyances.
View source
Greater Manchester Police
Update, test and release the Form 1157 mobile app with the revised structure and mandatory risk-information fields.
View source
Greater Manchester Police
Integrate case learning on risk identification, documentation and information sharing into Missing Person CPD and promoted-officer skills courses.
View source
Greater Manchester Police
Produce and publish a mental-health missing-persons CPD video covering risk assessment, conveyance responsibilities and structured hospital handovers.
View source
Greater Manchester Police
Require PRISM Care Plan triage staff to verify Form 1157 completion and attachment before closing relevant Care Plans.
View source See 3 more actions
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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.
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× 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
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
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
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
Open source report
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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 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
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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
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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 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
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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 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
Open published response
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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
Open published response
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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 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
Open published response
Concerns raised 1
Failure to pass relevant details, including next-of-kin information, to the s136 suite View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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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
Open source report
Concerns raised 1
Lack of formal written handovers of mental health presentation between police officers View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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 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
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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
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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
Open published response
Concerns raised 1
Lack of mandatory or refresher training on information handover during detainee booking View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
South Yorkshire Police
Review the booking-in sheet and create holding-area posters reminding officers to report illness, injuries and intoxication to the Custody Sergeant.
View source
South Yorkshire Police
Design force screen savers and deliver annual local CPD reinforcing information, roles and responsibilities when booking detainees into custody.
View source
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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.
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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
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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 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
Open published response
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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 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
Open published response
27 Nov 2020 Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to pass relevant incident and vulnerability information to ambulance and hospital staff View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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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
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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 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
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.