Recurring concern

Unreliable communication of detainee safety-critical risk information

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First reported 16 Apr 2015•Latest report 27 Mar 2024

Definition

What this concern includes

Includes failures in custody-related processes to identify, transfer, receive, review or communicate detainee safety-critical risk information to arresting officers, custody staff, custody healthcare personnel, Appropriate Adults and other directly responsible safeguards, including information arising before booking or during custody handover.

Not included

  • Excludes generic police or prison information-sharing failures where the information is not safety-critical detainee risk information.
  • Excludes failures to assess or manage detainee risk after the relevant information was reliably communicated.
  • Excludes general custody-record, detention-log or handover deficiencies unless they directly cause safety-critical detainee risk information to be missed or not communicated.
  • Excludes information-sharing processes for prisoners or patients outside a detainee-custody context unless the assertion explicitly supports the same custody risk-information interface.
Reports
5

Distinct published reports

Individual concerns
5

A report can raise multiple concerns

Date range
2015–2024

First to latest report issue date

Stated actions
4

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.

Crown Prosecution Service1
Department of Health and Social Care1
Greater Manchester Combined Authority1
Greater Manchester Police1
Home Office1
Lancashire County Council1
Lincolnshire Police1
Medacs Healthcare Limited1
Metropolitan Police Service1
Ministry of Housing, Communities and Local Government1
National Police Chiefs’ Council1
Pennine Care NHS Foundation Trust1
South Yorkshire Police1
Tameside Borough Council1
West Mercia 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

    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

  2. Inner North London

    AI-generated summary

    Jeroen ENSINK · 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

    Dr Jeroen Ensink was stabbed to death in a wholly unprovoked attack on 29 December 2015. The report identified multiple concerns involving police recording and information-sharing failures, including failures to identify and communicate possible mental health problems and issues in the handling of evidence and custody records.

    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 communicate identified mental health concerns to custody staff

    Wider context from the report

    “7. Both arresting officers formed the view that ████████ was suffering mental health or substance abuse problems, and both included these two factors in their statements, but the custody sergeant gave evidence that no mental health concerns were brought to his attention. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Worcestershire

    AI-generated summary

    STEWART AKINS · 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

    On 25 May 2015, Stewart Akins took his own life by placing himself in the path of a train after being released on conditional bail following his arrest. The report raised concerns that his repeated statements indicating a high risk of suicide or self-harm were not communicated to the prosecution or Magistrates’ Court, resulting in the risk being significantly downplayed and no objection to bail being made.

    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 communicate custody-recorded suicide and self-harm risks for full MG7 preparation

    Wider context from the report

    “(1) Throughout Mr. Akins' time in custody, entries were made on the custody record which recorded his repeatedly stated intention to end his own life. Statements to that effect were recorded as having been made, inter alia, to the Custody Sergeant, ████████ to a nurse, to a Forensic Medical Examiner ████████ and to the officer in charge of the investigation ████████ at the end of his police interview. The view was taken that he presented a high risk of suicide/self-harm. (2) The officer in charge of the investigation into the offences with which Mr. Akins was eventually charged, ████████ submitted an MG7 remand application form for consideration by the Crown Prosecution Service, and with a view to bail being opposed in the Magistrates' Court. In that form, she set out of objections on a number of grounds including a remand for Mr. Akins' own protection. However, in giving details substantiating that particular ground for opposing bail she stated: "AKINS has a problem with alcohol and mental health, clearly a combination that does not mix well. AKINS spoke of his suffering with post traumatic stress disorder (PTSD) and there is a real concern that, being charged with offences and now being NFA, he may pose a significant risk to not only those he encounters, but also to himself. It is therefore requested that a remand in custody be sought for AKINS own protection." (3) ████████ evidence at the inquest was that those details substantiating that ground for opposing bail ( for Mr. Akins' own protection ) were based solely on her own dealings with Mr. Akins, and not on what was recorded in the Custody Record. In fact, she was not aware of any of the entries recorded on the Custody Record and was therefore not aware of the level of risk of suicide/self-harm which those in charge of his detention felt that Mr. Akins presented. She had not sought to check the Custody Record for any such entries, nor to speak to the Custody Sergeant, nor had the Custody Sergeant sought to make her aware of such entries. (4) Because ████████ was unaware of the contents of these entries in the Custody Record, the description in the MG7 of the risk of suicide/self-harm which Mr. Akins presented was significantly downplayed. (5) In addition to that under-reporting of risk, prior to the hearing in the Magistrates' Court ████████ was informed by the Senior Crown Prosecutor that she was considering agreeing to bail with certain conditions. Those conditions did not address the issue of risk of suicide/self-harm, but ████████ accepted that she had not sought to raise this with the prosecutor. (6) A direct result of that under-reporting of risk of suicide/self-harm, and of ████████ failure to raise it with the prosecutor, was that the prosecutor was minded to agree to conditional bail as proposed. No objections to bail were raised with the Magistrates, and conditional bail was duly granted. (7) I am therefore concerned that no chain of communication appeared to be in place whereby ████████ had made aware of the risks highlighted in the Custody Record, so that an MG7 could be properly and fully prepared. (8) The explanations for this appear to be either: (i) that provision does not exist generally for such a chain of communication to be in place; or (ii) that provision does exist, and that ████████ and/or the Custody Sergeant(s) failed to operate in accordance with such provision. ”

    Source location

    STEWART AKINS · Prevention of Future Deaths report
    Page 1 · 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

    Require the responsible custody sergeant to verify and sign every Prisoner Escort Form before a detainee leaves or moves from custody, ensuring documented risks are communicated.

    Verbatim wording from the response

    “It is clear that there were failings in suitably communicating the degree of risk that was posed by Mr Akins following his movement from custody to the Magistrates Court. As a result of this incident West Mercia Police have immediately revised its’ practice to minimise risk and prevent future deaths by ensuring that all Prisoner Escort Forms (PER), whether completed by a detention officer or sergeant, are signed as accurate by the custody sergeant responsible for the detainees welfare prior to their release / movement from custody. The custody sergeant will have overall responsibility for ensuring that the risks are correctly documented and communicated. This practice will ensure that all known and documented risks contained within the custody record will travel with the person and properly inform their decision making processes.”

    Source location

    S-Akins-Response
    Page 1 · response
    Published 3 March 2016

    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

    Include in mandatory custody-sergeant training the requirement to highlight known risks and concerns to the officer in charge when considering an MG7 remand application.

    Verbatim wording from the response

    “West Mercia has also ensured that mandatory training for custody sergeants includes the awareness of highlighting known risks and concerns to the OIC upon consideration of a MG7 remand application. This will enable prosecutors and the courts to make fully informed decisions about a person’s vulnerabilities and needs.”

    Source location

    S-Akins-Response
    Page 1 · response
    Published 3 March 2016

    Open published response

  4. Central Lincolnshire

    AI-generated summary

    Mark Anthony Holdsworth · 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

    Mark Anthony Holdsworth was released from police custody at 00.26 hrs on 23 January 2015 and was later struck by a freight train after being laid on the railway line between Lincoln and Doncaster. The report states that he had recently threatened to kill himself, but this information was not brought to the attention of the arresting officers or custody staff before his release. The investigation concluded that he took his life.

    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 communicate recent suicide threat information to arresting and custody staff

    Wider context from the report

    “Shortly prior to his arrest, other officers took the complainant and her mother to Spring Lodge for an ABE/WVI interview. On route, ████████ Mother ████████ told the officers that Mr Holdsworth had said he would 'kill himself if released' This information was, I am told, later added to the incident log but was not drawn to the attention of either the arresting officers or the custody staff or Custody Sergeant. There is not criticism of the risk assessment procedure undertaken by the custody staff when Mr Holdsworth was booked in at Lincoln station but it's clear that they lacked the significant information that Mr Holdsworth had very recently threatened to kill himself. I am not sure what time the incident log was updated (I have not seen it) but I appreciate that it is impracticable to suggest that custody staff examine incident logs regularly because of the pressure of time and work. ”

    Source location

    Mark Anthony Holdsworth · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · 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

    Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police 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

    Failure to provide Appropriate Adults with relevant custody risk information

    Wider context from the report

    “She was not advised that Kesia had been assessed as intoxicated and arrival, nor that she had been seen by MEDACS, nor that she had threatened to jump off a bridge on her release. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report
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Data last updated 7 September 2026