Recurring concern

Unreliable safe-return arrangements after police custody release

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First reported 13 Feb 2023•Latest report 8 Jun 2023

Definition

What this concern includes

Includes dedicated police-custody release arrangements for getting released people safely to an address or other suitable accommodation, including provision or assessment of money and transport, guidance for release without an address, and coordination or escalation of material return-home needs.

Not included

Excludes general custody healthcare, detention, missing-person, prisoner-transfer and mental-health processes unless they directly concern safe return after police custody release.
Excludes generic poverty, homelessness or transport deficiencies where the police-custody release arrangement is not the identified unsafe condition.
Excludes failures in care or support after the person has safely reached home or suitable accommodation.
Excludes release arrangements for prisoners leaving prison or high-risk offenders unless the assertion specifically concerns release from police custody.

Reports: 2
Individual concerns: 3
Date range: 2023–2023
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Association of Ambulance Chief Executives1

College of Policing1

Dorset Police1

Dorset & Wiltshire Fire and Rescue Service1

Maritime and Coastguard Agency1

National Fire Chiefs Council1

National Police Air Service1

National Police Chiefs’ Council1

NHS England1

Niche Technology UK Limited1

Royal National Lifeboat Institution1

South Western Ambulance Service NHS Foundation Trust1

Wiltshire 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.

8 Jun2023
Dorset
Concerns raised1
1. Lack of guidance for releasing detainees without an address to reside at
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Maintain APP guidance on release of detainees without an address, including risk assessment, referrals and written self-referral information.
  Stated by College of Policing and National Police Chiefs’ CouncilStated completed
Respondent positions 5
1. Position
  National guidance on releasing detainees without an address will be addressed by the College of Policing rather than Dorset Police.
  Stated by Dorset PoliceRedirects responsibility
1. Position
  Many concerns in the report fall outside NHS England’s remit, so it can comment only on matters relevant to its functions.
  Stated by NHS EnglandOutside remit
2. Position
  Dorset Police are better placed to respond to many concerns addressed to multiple parties involved in the case.
  Stated by NHS EnglandRedirects responsibility
3. Position
  Police Custody Healthcare Services, rather than Liaison and Diversion, are responsible for custody physical healthcare and pre-release assessments.
  Stated by NHS EnglandRedirects responsibility
4. Position
  Existing Detention and Custody APP guidance, including signposting and referrals before release, is considered sufficient for releasing people without a fixed address.
  Stated by College of Policing and National Police Chiefs’ CouncilExisting arrangements considered sufficient
AI-generated summary

Ivan Rumenov Ignatov · 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

Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue 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
Lack of guidance for releasing detainees without an address to reside at
Wider context from the report
“iii. There is no guidance, that I am aware of, which addresses what should be done by police forces, and particularly custody sergeants, when a person is to be released without an address to reside at and I would request consideration is given to such guidance being provided. ”
Source location
Ivan Rumenov Ignatov · 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 APP guidance on release of detainees without an address, including risk assessment, referrals and written self-referral information.

Verbatim wording from the response
“other powers to detain (S34 Police and Criminal Evidence Act 1984). As set out below, in our experience, there would not have been sufficient grounds to detain Mr Ignatov for mental health assessment. This means that, regardless of his accommodation situation, he had to be released when the custody officer concluded that there were no grounds for continued detention. There is content in Detention and Custody APP on action to take if a person does not have an address when being released from custody. It must be borne in mind that it is not unusual for detainees to be of no fixed address, and it is noted in the APP that detainees could be referred to social care, hostels/refuges etc. There are two issues to be considered.”

Source location
Response from College of Policing
Page 3 · response
Published 12 June 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
National guidance on releasing detainees without an address will be addressed by the College of Policing rather than Dorset Police.

Verbatim wording from the response
“The College of Policing have again indicated that they will be addressing this concern with you directly in their response to the report, on the basis that this is also a National issue.”

Source location
Response from Dorset Police
Page 2 · response
Published 12 June 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
Many concerns in the report fall outside NHS England’s remit, so it can comment only on matters relevant to its functions.

Verbatim wording from the response
“It should be noted that many of the concerns raised in your Report do not fall under NHS England’s remit and I am only able to provide comment on those concerns relevant to NHS England. I note that you have addressed your Report to several parties involved in Ivan’s case, to include Dorset Police, who are better placed to respond to many of the concerns raised.”

Source location
Response from NHS England
Page 1 · response
Published 12 June 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
Dorset Police are better placed to respond to many concerns addressed to multiple parties involved in the case.

Verbatim wording from the response
“It should be noted that many of the concerns raised in your Report do not fall under NHS England’s remit and I am only able to provide comment on those concerns relevant to NHS England. I note that you have addressed your Report to several parties involved in Ivan’s case, to include Dorset Police, who are better placed to respond to many of the concerns raised.”

Source location
Response from NHS England
Page 1 · response
Published 12 June 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
Police Custody Healthcare Services, rather than Liaison and Diversion, are responsible for custody physical healthcare and pre-release assessments.

Verbatim wording from the response
“You also raised a concern over custody release practices and guidance. In Ivan’s case, while the Police did identify the need for referral to a mental health practitioner, it is not clear from your Report that a referral was made to the relevant Liaison & Diversion (L&D) Team or to the Police and Crime Commissioner (PCC) commissioned Police Custody Healthcare Services (PCHS) Team, who are commissioned by the Police directly, and who all advise the police on ‘Fitness to Release’ decisions. The L&D Team are a vulnerability service, not a local mental health crisis service. They are not responsible for providing any physical healthcare within a police custody setting or to undertake pre-release assessments, which falls under the remit of the PCHS.”

Source location
Response from NHS England
Page 1 · response
Published 12 June 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
Existing Detention and Custody APP guidance, including signposting and referrals before release, is considered sufficient for releasing people without a fixed address.

Verbatim wording from the response
“other powers to detain (S34 Police and Criminal Evidence Act 1984). As set out below, in our experience, there would not have been sufficient grounds to detain Mr Ignatov for mental health assessment. This means that, regardless of his accommodation situation, he had to be released when the custody officer concluded that there were no grounds for continued detention. There is content in Detention and Custody APP on action to take if a person does not have an address when being released from custody. It must be borne in mind that it is not unusual for detainees to be of no fixed address, and it is noted in the APP that detainees could be referred to social care, hostels/refuges etc. There are two issues to be considered.”

Source location
Response from College of Policing
Page 3 · response
Published 12 June 2023
Open published response
13 Feb2023
Wiltshire and Swindon
Concerns raised2
1. Lack of money for people taken into Police custody to return to their home address
2. Lack of ready access to transport for people taken into Police custody to return to their home address
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement the Ring B4 U Bring Scheme to capture detainees’ essential return-home information from arrest onward.
  Stated by Wiltshire PoliceStated completed
2. Action
  Implement the Vulnerable Detainee Transportation Scheme, including risk-based public transport assessment, funded taxis and police transport home for the most vulnerable detainees.
  Stated by Wiltshire PoliceStated completed
3. Action
  Provide training on the schemes to all new Custody Sergeants.
  Stated by Wiltshire PoliceStated planned
Respondent positions 1
1. Position
  Implemented detainee transportation schemes fully address the identified safety issues, so no additional measures are proposed.
  Stated by Wiltshire PoliceExisting arrangements considered sufficient
AI-generated summary

Michael POULTON · 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

Michael POULTON was released from police custody on 22 June 2019, with arrangements for police transport to a family member’s home, but there was a delay and he left the custody suite. He was found suspended by a ligature in a field the following day; concerns related to people in police custody lacking money, communication with family, or ready access to transport home, and to arrangements for facilitating their return.

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 money for people taken into Police custody to return to their home address
Wider context from the report
“(1) People are being taken into Police custody, some distance from their home address, without having any money or means of communicating with family, or ready access to transport from the custody suite, to their home address. ”
Source location
Michael POULTON · 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
Lack of ready access to transport for people taken into Police custody to return to their home address
Wider context from the report
“(1) People are being taken into Police custody, some distance from their home address, without having any money or means of communicating with family, or ready access to transport from the custody suite, to their home address. ”
Source location
Michael POULTON · 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
Implement the Ring B4 U Bring Scheme to capture detainees’ essential return-home information from arrest onward.

Verbatim wording from the response
“In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force’) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme.”

Source location
Response from Wiltshire Police
Page 1 · response
Published 24 February 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
Implement the Vulnerable Detainee Transportation Scheme, including risk-based public transport assessment, funded taxis and police transport home for the most vulnerable detainees.

Verbatim wording from the response
“In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force’) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme.”

Source location
Response from Wiltshire Police
Page 1 · response
Published 24 February 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
Provide training on the schemes to all new Custody Sergeants.

Verbatim wording from the response
“Training on these schemes will be given to all new Custody Sergeants.”

Source location
Response from Wiltshire Police
Page 2 · response
Published 24 February 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
Implemented detainee transportation schemes fully address the identified safety issues, so no additional measures are proposed.

Verbatim wording from the response
“In anticipation of the closure of Melksham Custody in February 2023, Wiltshire Police (‘the Force’) have developed and implemented a scheme entitled the Vulnerable Detainee Transportation Scheme.”

Source location
Response from Wiltshire Police
Page 1 · response
Published 24 February 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of guidance for releasing detainees without an address to reside at

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised2

Lack of money for people taken into Police custody to return to their home address

Lack of ready access to transport for people taken into Police custody to return to their home address

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 5

Actions described in response 3

Respondent positions 1