Recurring concern

Failure of police post-incident performance learning and remediation

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First reported 27 Nov 2020•Latest report 29 Sep 2025

Definition

What this concern includes

Includes failures in police post-incident performance learning and remediation, including thresholds that prevent reflective practice, absent or inadequate individual or organisational review, and failure to implement remediation for identified performance failings.

Not included

  • Excludes generic organisational learning or incident-investigation failures that are not specifically tied to police post-incident performance review, reflection or remediation.
  • Excludes clinical, education, care, transport and other non-police learning processes unless the assertion explicitly concerns the police post-incident performance-learning process.
  • Excludes routine training or professional-development deficiencies where no post-incident performance failing or safety-related learning need is identified.
  • Excludes failures in the underlying police operational response when no deficiency in post-incident review, reflection or remediation is asserted.
Reports
6

Distinct published reports

Individual concerns
6

A report can raise multiple concerns

Date range
2020–2025

First to latest report issue date

Stated actions
3

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.

Metropolitan Police Service5
British Transport Police1
City of London Police1
College of Policing1
Department of Health and Social Care1
Greater London Authority1
HM Prison and Probation Service1
Home Office1
Independent Office for Police Conduct1
London Borough of Redbridge1
Mayor's Office for Policing and Crime1
Ministry of Justice1
Royal College of Emergency Medicine1

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. East London

    AI-generated summary

    Jake Hickey Girton · 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

    Jake Hickey Girton was admitted to psychiatric hospital following suicidal ideation and serious, sustained alcohol misuse, and was later arrested after an incident on the ward. He was released from police custody without the psychiatric Trust being informed and was subsequently found deceased at home on 26 January 2024; the inquest identified concerns about the failure to notify the Trust and the lack of evidence of reflection or remediation by the Metropolitan Police Service.

    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 reflect on or remediate identified performance failings

    Wider context from the report

    “2. Despite a Directorate of Professional Standards review, there is no evidence that the MPS identified any shortcoming in their performance in dealing with Jake, consequently no evidence exists of any reflection or remediation of this failing. ”

    Source location

    Jake Hickey Girton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 DPS review was appropriate and went as far as expected because it identified no conduct, performance or organisational learning.

    Verbatim wording from the response

    “The MPS Directorate of Professional Standards (DPS) conducted a comprehensive review into this matter as per their remit and standard operating procedure. It was determined that this incident did not meet the definition of a Death or Serious Injury¹ (DSI) following police contact as defined in the Independent Office for Police Conduct (IOPC) Statutory Guidance. Upon conducting DSI reviews, the expectation is for DPS to also consider whether there is an obvious conduct matter, performance matter or opportunity for individual or organisational learning. In this instance, the review did not identify any such learning.”

    Source location

    Response from Metropolitan Police
    Page 5 · response
    Published 3 October 2025

    Open published response
  2. East London

    AI-generated summary

    Zara Natasha Aleena · 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

    Zara Natasha Aleena died at the Royal London Hospital on 26 June 2022 after sustaining a severe traumatic brain injury during an unprovoked attack while walking home in Ilford. The report identifies concerns about understaffing, risk assessment, information sharing, supervision, recall procedures and coordination across the Probation Service, police and other agencies, as well as concerns about training and reporting of predatory behaviour.

    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

    Threshold for reflective practice set too high

    Wider context from the report

    “(18)There were clearly learning points for the police constables, police sergeants and the local intelligence team. The MPS rejected the DPS recommendation for reflective learning, “as there was no failing in performance or conduct”. It is of concern that the threshold for reflective practice is set too high. ”

    Source location

    Zara Natasha Aleena · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    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 MPS cannot unilaterally lower the Reflective Practice Review Process threshold because it is subject to statutory guidance.

    Verbatim wording from the response

    “The MPS recognises the Coroner’s concern about the threshold that is applied to RPRP. Since RPRP is subject to statutory guidance, the MPS is unable to make unilateral changes. In this case, it was assessed by the Appropriate Authority that learning for officers and staff did not meet the threshold for RPRP. As discussed above, the MPS has made changes since 2022 and the Appropriate Authority for such decisions is now independent of BCUs. They are aware that if they consider the threshold for RPRP is not met, Learning Through Reflection could be used and all MPS officers and staff have responsibilities towards continual learning and professional development.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 2 August 2024

    Open published response
  3. Inner North London

    AI-generated summary

    Mohammed AKRAMUZZAMAN · 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

    Mohammed Akramuzzaman, aged 39, was found in cardiac arrest beside Euston Station on 8 December 2023 after spending the night outside. His death involved alcohol-related ketoacidosis and hypothermia. Concerns included the adequacy of the British Transport Police assessment, the decision not to return to check on him despite the cold conditions, and the lack of identified organisational learning after his death.

    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 organisational learning and procedural change after a serious incident

    Wider context from the report

    “5. I was told that the BTP officers had reflected a lot about this incident in the time since, and had learnt a lot. However, when giving their evidence they struck me as defensive, and they were unable to point to any specific learning or any changes in their procedures following Mr Akramuzzaman’s death. Whilst I readily accepted that the officers had talked about Mr Akramuzzaman since his death, I did not gain the impression of a culture of learning. The sergeant told me that before the inquest, he had not known about the existence of ketoacidosis. The officers reminded me that they are not healthcare professionals. However, as I explained in court, I was not suggesting that they should have a particular understanding of ketoacidosis. Mr Akramuzzaman could have been suffering from any number of medical conditions. He could have sustained a subtle head injury. He could have had diabetes (which, as it happens, can also result in ketoacidosis). He could have had epilepsy. The list goes on. Mr Akramuzzaman did not need the BTP officers to be doctors in order to survive this episode, but he was probably already confused when officers dealt with him, and he needed them to make an appropriate assessment and to take appropriate action as BTP officers. The sergeant told me that he thought learning should be undertaken by BTP at an organisational level. ”

    Source location

    Mohammed AKRAMUZZAMAN · Prevention of Future Deaths report
    Page 3 · 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

    Circulate a force-wide bulletin highlighting learning from the incident.

    Verbatim wording from the response

    “In response to the IOPC recommendations, a force wide bulletin was circulated on 19 July 2024 to highlight the learnings identified as a result of this incident. This bulletin is exhibited to this response [EXHIBIT 1].”

    Source location

    Response from British Transport Police
    Page 3 · response
    Published 7 June 2024

    Open published response
  4. Inner South London

    AI-generated summary

    Mr Ian McDonald Taylor · 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

    Mr Ian McDonald Taylor suffered a cardiac arrest after a physical altercation while in police detention and died in hospital. Concerns included the police officer’s assessment and communication of Mr Taylor’s breathing difficulties, access to his inhaler while awaiting an ambulance, and the exceptionally delayed ambulance response.

    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 identify and address officer training or attitudinal deficits through supervision

    Wider context from the report

    “In court he was asked if he had learnt any lessons from the incident and he did not acknowledge he had. He was asked if he would do anything different in future, he made excuses for his comments and he said that he would be more sensitive in future. He was not able to answer a question about what considerations should be made to form the view somebody did not need hospital. He did not accept that he had made an inadequate risk assessment. He did not accept that such comments could have or might in future contribute to death by indicating a lack of urgency to a sergeant not at the scene. He was given an opportunity to make any other comment and could not bring himself to apologize to the family. There was no evidence heard in court of the content or effect of supervision of the officer after the incident or whether training or attitudinal deficits had been identified and addressed. The family are concerned as to whether the officer should be suspended pending further investigations, and I disclose that merely as a measure of their level of concern about public safety, as it is inappropriate for me to make any such recommendation. ”

    Source location

    Mr Ian McDonald Taylor · Prevention of Future Deaths report
    Page 3 · 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 Reflective Practice Review Process for the officer, including reflection on the missed apology and identification of any additional training needs.

    Verbatim wording from the response

    “The AA has determined that the conduct does not meet the threshold for justifying disciplinary proceedings. The AA has identified practice requiring improvement and determined that the officer will be referred the reflective practice review process, as set out in Part 6 of the Police (Conduct) Regulations 2020. In particular the AA has determined that the reflective practice review process will include an opportunity for the officer to reflect on the missed opportunity to offer an apology to Mr Taylor’s family.”

    Source location

    Response from Metropolitan Police
    Page 3 · response
    Published 20 September 2022

    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

    The conduct did not meet the threshold for disciplinary proceedings, so no disciplinary action was pursued.

    Verbatim wording from the response

    “The AA has determined that the conduct does not meet the threshold for justifying disciplinary proceedings. The AA has identified practice requiring improvement and determined that the officer will be referred the reflective practice review process, as set out in Part 6 of the Police (Conduct) Regulations 2020. In particular the AA has determined that the reflective practice review process will include an opportunity for the officer to reflect on the missed opportunity to offer an apology to Mr Taylor’s family.”

    Source location

    Response from Metropolitan Police
    Page 3 · response
    Published 20 September 2022

    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

    A further investigation was unnecessary because existing body-worn video and inquest evidence established the officer’s behaviour, while reflective practice provided appropriate intervention.

    Verbatim wording from the response

    “I agree that this is an appropriate intervention. ████████ behaviour is evidenced in the BWV capturing his comments at the time, and the record of his evidence to the inquest. A further investigation therefore does not appear to be necessary in order to establish the extent of his behaviour or test the evidence. Under the Police (Conduct) Regulations 2020, the appropriate authority has the power to refer an officer to the reflective practice review process without an investigation. The Home Office Guidance on Conduct, Efficiency and Effectiveness 2020 states that the reflective practice review process is intended to:”

    Source location

    Response from IOPC
    Page 4 · response
    Published 20 September 2022

    Open published response
  5. Inner South London

    AI-generated summary

    Mr Joseph Agnew · 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

    Mr Joseph Agnew suffered an out-of-hospital cardiac arrest after being removed from a bus and left in a bus shelter, was later found unresponsive, and died five days after admission with a devastating brain injury. The report raised concerns about police training and assessment of intoxicated people with reduced responsiveness, including recognising snoring and monitoring breathing, post-incident learning, and the lack of a safe referral facility for acutely intoxicated homeless people found on buses.

    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 of post-incident performance review and organisational learning processes

    Wider context from the report

    “3. For the attention of the MPS: Two MPS officers who attended the scene gave evidence that they would do nothing different even in hindsight. No evidence was presented as to the post incident performance reviews and individual learning, and there is uncertainty about the adequacy of the corporate process of learning from incidents. There is a lack of assurance to the public that the risks related to the decisions of these officers or other incidents have been mitigated for the future. ”

    Source location

    Mr Joseph Agnew · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  6. 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 learn from incidents and change practice

    Wider context from the report

    “The police officer defended all of his actions robustly. I could not see that he had learnt anything as a result of these events or that anything about his practice would change in the future. ”

    Source location

    Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report
    Page 3 · 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