Recurring concern

Unreliable multi-agency communication procedures

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First reported 29 May 2013•Latest report 16 Jun 2026

Definition

What this concern includes

Includes failures of explicitly multi-agency communication procedures that impair the timely, accurate and complete exchange of safety-relevant information between involved agencies, including the anchor's prison-services communication failure.

Not included

Excludes generic communication, training, staffing or coordination deficiencies where no explicitly multi-agency communication procedure is identified.
Excludes failures confined to a single organisation's internal communication process.
Excludes failures of a separately named pathway, system or hazard when that concern provides the more specific supported boundary.
Excludes neutral descriptions of multi-agency working without an identified unsafe communication condition.

Reports: 134
Individual concerns: 145
Date range: 2013–2026
Stated actions: 303

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.

Department of Health and Social Care17

NHS England17

Ministry of Justice14

HM Prison and Probation Service10

Home Office8

Recipient name withheld6

Metropolitan Police Service5

Association of Ambulance Chief Executives4

East London NHS Foundation Trust4

National Police Chiefs’ Council4

Care Quality Commission3

College of Policing3

Greater Manchester Mental Health NHS Foundation Trust3

Greater Manchester Police3

NHS Greater Manchester Integrated Care Board3

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.

21 Apr2015
Brighton and Hove
Concerns raised1
1. Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
This report raised 6 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Bruce LONGDEN · 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

Bruce LONGDEN’s death was investigated by an inquest, but the circumstances of the death are referred to separately in the Record of Inquest. The substantive concerns included failures to follow Sussex Partnership Trust protocols, poor communication between trusts, inadequate understanding of his mental health condition and terminology, and delayed reporting of his absconsion to Sussex Police.

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
Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust
Wider context from the report
“(1) Sussex Partnership Trust are apparently unaware of their own protocols in connection with :- a) Transfer of Sussex Partnership Trust patients to the acute hospital and b) Observations and Therapeutic Engagement policy These policies were not employed. If they had been the outcome may have been different for Mr Bruce LONGDEN as he would have been specially and accompanied and would not have had the opportunity to abscond. 2)Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust 3)Poor communication within Brighton & Sussex University Hospital Trust particularly: • Failure to appreciate the significance of Mr Bruce Longden’s mental health condition • Failure to understand the terminology used by the mental health liaison team • Failure of the Mental Health Team to adhere to commonly understood terminology • Failure to report the absconsion timely to Sussex Police resulting in a window of opportunity to search for and, potentially, find Mr Bruce Longden to be lost ”
Source location
Bruce LONGDEN · Prevention of Future Deaths report
Page 1 · concerns
Open source report
17 Apr2015
Staffordshire South
Concerns raised1
1. Lack of direct communication between offender managers and hospital clinicians before recall decisions
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 2
1. Action
  Replace and update the recall guidance governing recall processes.
  Stated by Directorate of Probation in NOMSStated completed
2. Action
  Remind all probation staff of recall procedures through senior-leader communication.
  Stated by Directorate of Probation in NOMSStated planned
Respondent positions 1
1. Position
  Existing recall guidance is considered clear and sufficient to ensure recall follows full consideration of relevant facts.
  Stated by Directorate of Probation in NOMSExisting arrangements considered sufficient
AI-generated summary

Mark Groombridge · 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 Groombridge was in the community on licence from prison when a recall warrant was issued. He was arrested while an inpatient in a psychiatric unit and taken to HMP Dovegate, where he died by suicide on 27 December 2013 after jumping head first from a bed in the prison health care centre. The concerns identified included a lack of direct communication between the local offender manager and the clinician before recall paperwork was issued, and confusion among probation staff about the recall 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
Lack of direct communication between offender managers and hospital clinicians before recall decisions
Wider context from the report
“(1) Before the recall paperwork was issued there was no direct conversation between the local offender manager and the clinician responsible for Mr Groombridge’s care in hospital. Should it not be policy for such a discussion to take place in any case where an offender is in hospital (be it for physical or mental reasons) before the recall is issued? ”
Source location
Mark Groombridge · 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
Replace and update the recall guidance governing recall processes.

Verbatim wording from the response
“Probation Instruction 07/2013 has now been replaced by Probation Instruction 27/2014, with the same title, which became effective from 1 June 2014. It was updated on 1 February 2015. The Director of Probation is of view that the guidance given on the recall process remains clear, but is asking Deputy Directors to ensure that all probation staff are reminded of the procedures by 31 August. Public Protection Casework Section (PPCS), will be issuing a Senior Leaders Bulletin covering recall actions which will include a reminder of processes for all Probation staff to follow, PPCS will also be organising Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year. These forums will give staff and managers the opportunity to come together to discuss issues surrounding recall and review practice.”

Source location
2015-0142-Response-by-NOMS
Page 2 · response
Published 17 April 2015
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
Remind all probation staff of recall procedures through senior-leader communication.

Verbatim wording from the response
“Probation Instruction 07/2013 has now been replaced by Probation Instruction 27/2014, with the same title, which became effective from 1 June 2014. It was updated on 1 February 2015. The Director of Probation is of view that the guidance given on the recall process remains clear, but is asking Deputy Directors to ensure that all probation staff are reminded of the procedures by 31 August. Public Protection Casework Section (PPCS), will be issuing a Senior Leaders Bulletin covering recall actions which will include a reminder of processes for all Probation staff to follow, PPCS will also be organising Recall Practitioner Forums in each National Probation Service (NPS) division at the end of the year. These forums will give staff and managers the opportunity to come together to discuss issues surrounding recall and review practice.”

Source location
2015-0142-Response-by-NOMS
Page 2 · response
Published 17 April 2015
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 recall guidance is considered clear and sufficient to ensure recall follows full consideration of relevant facts.

Verbatim wording from the response
“At the time of Mr Groombridge’s death the relevant guidance concerning the recall of offenders was Probation Instructions 07/2013 (Recall Review & Re-release of Recall Offenders) and 08/2013 (Determinate Sentenced Prisoners transferred under the Mental Health Act 1983). This guidance has been reviewed and the Director of Probation is of the view that the processes to be followed in that guidance were clear. The guidance states that offender managers are required to gather evidence and assemble the relevant facts to support a request for recall and that this will include liaising with anyone directly involved, including medical staff at a hospital at which an offender was a patient.”

Source location
2015-0142-Response-by-NOMS
Page 1 · response
Published 17 April 2015
Open published response
26 Feb2015
Leicester City and South Leicestershire
Concerns raised1
1. Lack of nationally agreed standard assessment forms for cross-organisational mental health transfers
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Simion Costin · 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

Simion Costin died at Leicester Royal Infirmary on 25 March 2014 after admission with a self-inflicted neck incision, having attended the hospital twice in the preceding four days and been discharged after mental health assessments. Concerns included inconsistent approaches to patient assessment and the second discharge plan being based on incomplete data, with communication challenges when care crossed hospital or regional boundaries.

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 nationally agreed standard assessment forms for cross-organisational mental health transfers
Wider context from the report
“(1) Evidence was heard that during patient assessment, the same approach was not adopted by all clinicians. As a result standardised assessments forms have now been developed and are being used within the Leicestershire Partnership Trust. This includes the need to involve family / friends in the assessment (with the consent of the patient). However, it was recognised that mental health care often crosses borders with an initial assessment made in a neighbouring hospital but then the patient transferred for care and treatment elsewhere. The Consultant gave evidence that it would be better if there were nationally agreed standard forms so that communication in these complex situations is best served. ”
Source location
Simion Costin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
5 Jan2015
Berkshire
Concerns raised1
1. Failure to escalate and notify trolley users of the known cot-side locking risk
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 1
1. Action
  Implement and re-instate a Trust-wide trolley safety campaign through computer screensavers, posters and updated training-website instructions.
  Stated by Royal Berkshire NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  MHRA considered a Medical Device Alert unnecessary because evidence and risk assessment did not justify additional safety messaging.
  Stated by Medicines and Healthcare products Regulatory AgencyNo action considered necessary
1. Position
  Available reports indicated the QA3 side-rail problem was local to RBH rather than a wider problem across hospitals.
  Stated by Medicines and Healthcare products Regulatory AgencyDisputes the concern
AI-generated summary

James Wilson Fyfe · 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

James Wilson Fyfe died on 21 April 2011 from pneumonia significantly contributed to by a cervical spine fracture sustained when he fell from a hospital trolley after its cot side gave way. Concerns related to the trolley remaining raised but unlocked due to design, maintenance and use issues, and to uncertainty about whether the known hazard had been communicated to other users of the trolley.

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 escalate and notify trolley users of the known cot-side locking risk
Wider context from the report
“(2) The Jury were informed that MHRA were aware of the investigations of the incident trolley but that it did not appear that the issue had been escalated and notified to all Hospital Trusts and agencies that used this type of trolley. The MHRA’s actions in being informed of this potential hazard remain unclear, with particular reference to passing on the known risk to such trolley users. ”
Source location
James Wilson Fyfe · 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
Implement and re-instate a Trust-wide trolley safety campaign through computer screensavers, posters and updated training-website instructions.

Verbatim wording from the response
“3. After the incident the Trust instigated a “Remember ‘Clunk – Click’ every trip” campaign across the Trust. The campaign included placing a ‘Clunk – Click’ screen saver on Trust computers, placing campaign posters strategically across the Trust and ensuring updated user instructions were added to the Trust’s training website. This campaign was re-instigated across the Trust in January 2015.”

Source location
2015-0099-Response-by-Royal-Berkshire-NHS-Trust
Page 2 · response
Published 5 January 2015
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
MHRA considered a Medical Device Alert unnecessary because evidence and risk assessment did not justify additional safety messaging.

Verbatim wording from the response
“MHRA did not publish a Medical Device Alert (MDA) concerning the QA3 Patient Trolley. At the time of the incident 11,090 QA3 trolleys had been produced with the same design of locking mechanism for the side rails. There were no prior related incidents reported to either MHRA or Anetic Aid Ltd for the period the trolley had been placed on the market, 1998 to 2011. It is important to note that not all incidents result in the issue of a MDA. MHRA received 10,984 incident reports (relating to 21,729 incidents) in 2011 and issued 114 MDAs. There would be a real risk of diluting the impact and importance of alerts if the system were to be used to distribute large numbers of alerts. In addition, Government agencies are trying to reduce the burden on the NHS and are working with fewer resources themselves.”

Source location
2015-0099-Response-by-Medicines-Healthcare-Products-Regulatory-Agency
Page 2 · response
Published 5 January 2015
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
Available reports indicated the QA3 side-rail problem was local to RBH rather than a wider problem across hospitals.

Verbatim wording from the response
“MHRA review of incident - 2015 The current version of the QA3 trolley uses the same type of locking mechanism and it is essentially unchanged, having the same characteristics. Anetic Aid Ltd state that QA3 sales now total 11,680 units. Since the incident in 2011 there have been no further reports to MHRA or to the manufacturer of any users other than RBH experiencing problems with the side rails not locking when they are raised. RBH sent us reports in March 2013 and November 2014 which were added to the surveillance database, each detailing one failure.”

Source location
2015-0099-Response-by-Medicines-Healthcare-Products-Regulatory-Agency
Page 2 · response
Published 5 January 2015
Open published response
24 Nov2014
Surrey
Concerns raised1
1. Failure of communication between police and hospital staff about missing-person status
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 2
1. Action
  Review the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.
  Stated by Surrey PoliceStated in progress
2. Action
  Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.
  Stated by Surrey PoliceStated in progress
Respondent positions 1
1. Position
  The communication failure concerned notification of an absent classification, not mental health issues in the wider context.
  Stated by Surrey PoliceDisputes the concern
AI-generated summary

William Philip Hafele · 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

William Philip Hafele, who had a history of mental ill health and alcohol dependence, was admitted to hospital after being found intoxicated and wanting to take his own life. After leaving the ward and being redesignated by police from missing to absent, no immediate enquiries were made; he was later found dead in a hotel room after suffocating using helium gas. The principal concerns related to inadequate training, risk assessment, communication, and understanding of responsibilities between the police and hospital staff.

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 communication between police and hospital staff about missing-person status
Wider context from the report
“• Training procedures in respect of the police and hospital staff on Elgar Ward in the case of reports of missing persons and lack of understanding of areas of responsibility and appropriate actions. • Critical information required to make an informed risk assessment as to whether was missing or absent was omitted. • The decision to re classify from missing to absent was not communicated to the hospital • As a result no enquiries or investigations were made by any agency to ascertain Mr Hafele’s whereabouts • Adequate training on the Surrey Wide Response Agreement and Surrey Police Missing Person Procedure did not take place • In relation to the Police, specific training with regards to risk assessments for mental health patients was lacking • Surrey Police TPT briefing training did not correspond to the definition of Absent given in the Surrey Police Missing Person • Ineffective communications between Police and Elgar Ward ”
Source location
William Philip Hafele · 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
Review the Force Missing Person Policy with NHS partners to address missing-person responsibilities and communication issues.

Verbatim wording from the response
“The Force’s Missing Person Policy (MPP) is currently under review. The existing MPP, a policy jointly produced with NHS partners, is a comprehensive document setting out the way in which risk can be assessed and appropriate levels of responsibility:”

Source location
2014-0511-Response-by-Surrey-Police
Page 1 · response
Published 24 November 2014
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
Continue working with NHS and medical partners to establish effective communication channels and consistent responses to mental-health issues.

Verbatim wording from the response
“The Force is committed to working with NHS and other medical partners to ensure effective channels of communication and consistent response and handling of mental ill health issues.”

Source location
2014-0511-Response-by-Surrey-Police
Page 5 · response
Published 24 November 2014
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 communication failure concerned notification of an absent classification, not mental health issues in the wider context.

Verbatim wording from the response
“8. “Ineffective communications between police and Elgar Ward””

Source location
2014-0511-Response-by-Surrey-Police
Page 4 · response
Published 24 November 2014
Open published response
14 Nov2014
Teesside
Concerns raised1
1. Lack of dialogue between police and local A&E departments about treatment misunderstandings
This report raised 3 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 4
1. Action
  Establish joint guidance for assessing, treating, discharging and communicating information about aggressive or medically unwell detainees attending emergency departments.
  Stated by NHS Durham Dales, Easington and Sedgefield CCG and NHS Hartlepool and Stockton on Tees CCG and NHS North Durham CCG and NHS South Tees Clinical Commissioning GroupStated completed
2. Action
  Keep the Durham emergency-department process under review and discuss arising concerns monthly in relevant meetings.
  Stated by NHS Durham Dales, Easington and Sedgefield CCG and NHS Hartlepool and Stockton on Tees CCG and NHS North Durham CCG and NHS South Tees Clinical Commissioning GroupStated completed
3. Action
  Issue Cleveland Police guidance for managing aggressive detainees transferred to emergency or mental-health services, incorporating agreed police and NHS arrangements.
  Stated by Cleveland PoliceStated planned
1. Action
  Review the effectiveness of the guidance after six months.
  Stated by Cleveland PoliceStated planned
AI-generated summary

Kirk William Williams · 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

Kirk William Williams ingested several drugs and displayed highly agitated and aberrant behaviour before being restrained by police. Although one officer considered that he should be taken to hospital, he was taken to a police station and later suffered cardiac arrest and died in hospital. The concerns included differing understandings between police and A&E staff about treating aggressive detainees, and the absence of clear dialogue or guidance for managing such medical emergencies.

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 dialogue between police and local A&E departments about treatment misunderstandings
Wider context from the report
“(2) Some police officers still consider that notwithstanding that they may be faced with a medical emergency, A&E departments will not treat violent or aggressive patients. (3) The various consultants that gave evidence are clear that they will treat violent patients provided that (a) treatment is warranted and (b) they are provided with sufficient assistance from either or both the police or security staff. (4) It therefore follows that there is a mismatch in perception and expectations between Cleveland police officers and local A&E staff. (5) There did not appear to be a sufficiency of understanding within Cleveland Constabulary about how and whether detainees may be treated at A&E departments. (6) Further or alternatively, the insufficiency in understanding lies with A&E consultants and their perception of what type of patients will be accepted and allowed to be treated in their departments. (7) There does not appear to be a dialogue between Cleveland Constabulary and local A&E departments to address these particular misunderstandings or misconceptions. (8) There does not appear to be any memorandum of understanding or guideline to cover aggressive detainees in police custody being taken to A&E departments. (9) Without a fuller understanding of the true position, police officers will continue to be faced with the perennial dichotomy of whether to take an aggressive medical emergency detainee to an A&E department for treatment or to a police station to prevent self harm or harm to others. ”
Source location
Kirk William Williams · 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
Establish joint guidance for assessing, treating, discharging and communicating information about aggressive or medically unwell detainees attending emergency departments.

Verbatim wording from the response
“A meeting was held between the Medical Directors and senior A&E medical staff of both Foundation Trusts and Detective Chief Superintendent ████████ from Cleveland Police.”

Source location
2014-0499-Response-by-South-Tees-Clinical-Commissioning-Group
Page 1 · response
Published 14 November 2014
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
Keep the Durham emergency-department process under review and discuss arising concerns monthly in relevant meetings.

Verbatim wording from the response
“The process is kept under review by the Trust and any arising issues are discussed on a monthly basis in relevant meetings depending on the nature of the concerns raised, i.e. frequent attenders; mental health, drugs or alcohol related issues or violence and aggression incidents. The Trust has confirmed that some of those meetings do include representatives from Durham Constabulary.”

Source location
2014-0499-Response-by-South-Tees-Clinical-Commissioning-Group
Page 2 · response
Published 14 November 2014
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
Issue Cleveland Police guidance for managing aggressive detainees transferred to emergency or mental-health services, incorporating agreed police and NHS arrangements.

Verbatim wording from the response
“At point 8 in your report you identified that there did not appear to be a Memorandum of Understanding or guidance to cover aggressive detainees in Custody being taken to A&E Departments.”

Source location
2014-0499-Response-by-Cleveland-Police
Page 1 · response
Published 14 November 2014
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
Review the effectiveness of the guidance after six months.

Verbatim wording from the response
“It is my intention to review the effectiveness of the guidance in six months’ time and to take any appropriate action where necessary, whether that is amendments to the guidance in conjunction with the two Trusts, or further training to ensure staff are aware of and are implementing the guidance.”

Source location
2014-0499-Response-by-Cleveland-Police
Page 2 · response
Published 14 November 2014
Open published response
15 Oct2014
Manchester (North)
Concerns raised1
1. Lack of communication between GMP and MEDACS about the existence of an escalation protocol
This report raised 6 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
  Disseminate the MEDACS Escalation Policy to all custody staff by email and through Custody Branch Orders.
  Stated by Greater Manchester PoliceStated completed
AI-generated summary

Lucasz Lewandowski · 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

Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

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 communication between GMP and MEDACS about the existence of an escalation protocol
Wider context from the report
“2. Lack of communication between GMP and MEDACS regarding the existence of their escalation protocol resulting in the delayed attendance of an FME. ”
Source location
Lucasz Lewandowski · 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
Disseminate the MEDACS Escalation Policy to all custody staff by email and through Custody Branch Orders.

Verbatim wording from the response
“The Custody Branch acknowledges and agrees that it is a concern that the custody staff were not aware of the MEDACS Escalation Policy, or that in all appropriate instances staff should escalate calls in order to secure medical care provision, in the most efficient manner to those who need it most.”

Source location
2014-0445-Response-by-Greater-Manchester-Police
Page 2 · response
Published 15 October 2014
Open published response
19 Sep2014
Inner North London
Concerns raised2
1. Failure of multi-agency communication procedures
2. Failure of multi-agency communication procedures
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 2
1. Action
  Implement local information-sharing and multi-agency communication policies, including staff reminders on gathering, assessing and sharing risk information.
  Stated by Pentonville Prison and Thameside PrisonStated completed
2. Action
  Enable prison and healthcare staff at Thameside to work together at reception and use a dedicated form to communicate relevant prisoner information.
  Stated by Pentonville Prison and Thameside PrisonStated completed
AI-generated summary

Satheeskumar MAHATHEVAN · 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

Satheeskumar Mahathevan hanged himself in his cell at HM Prison Pentonville on 14 April 2013. The report identified concerns about failures in information sharing, multi-agency communication procedures, and inadequate training for prison staff.

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 multi-agency communication procedures
Wider context from the report
““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”
Source location
Satheeskumar MAHATHEVAN · 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 of multi-agency communication procedures
Wider context from the report
““Failures in relation to information sharing, multi agency communication procedures and inadequate training for staff at the prison services have contributed to this accident.” ”
Source location
Satheeskumar MAHATHEVAN · 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 local information-sharing and multi-agency communication policies, including staff reminders on gathering, assessing and sharing risk information.

Verbatim wording from the response
“Local policies are now in place at HMP Pentonville and HMP Thameside to ensure that information is shared appropriately and that there is effective communication between prison staff and the healthcare provider. At both prisons, staff involved in the reception and first night processes have been reminded of the need to gather all relevant information, including information received from court, and of the factors that they should consider when assessing risk and sharing information between agencies.”

Source location
2014-0412-Response-by-NOMS
Page 1 · response
Published 19 September 2014
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
Enable prison and healthcare staff at Thameside to work together at reception and use a dedicated form to communicate relevant prisoner information.

Verbatim wording from the response
“At HMP Thameside prison and healthcare staff work together at the same counter. A new form has been designed specifically to ensure that all relevant information, including that received from the court, is communicated between the two groups of staff.”

Source location
2014-0412-Response-by-NOMS
Page 2 · response
Published 19 September 2014
Open published response
28 Jul2014
Oxfordshire
Concerns raised1
1. Failure to pass high-risk information between police forces and control rooms
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 1
1. Action
  Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.
  Stated by Thames Valley PoliceStated completed
Respondent positions 2
1. Position
  Thames Valley Police disputes that it failed to inform Gloucestershire Police of the relevant welfare concerns.
  Stated by Thames Valley PoliceDisputes the concern
1. Position
  Gloucestershire Police was responsible for assessing whether the shared information required a different intervention.
  Stated by Thames Valley PoliceRedirects responsibility
AI-generated summary

Suzanne Cammell · 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

Suzanne Cammell died on 3 October 2013 after lying beneath the wheels of a lorry in a layby near Burford Golf Club; she sustained severe blunt head injuries when the lorry drove away. The principal concern was that high-risk information about the incident and a previous similar incident may not have been communicated by Thames Valley Police to Gloucestershire Constabulary or made available to the officer conducting a welfare check.

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 high-risk information between police forces and control rooms
Wider context from the report
“(1) There was also an incident on 23 September 2013 in Gloucestershire when Ms Cammell had been sectioned under Section 136 of the MHA because she had been seen placing her head under the wheels of a recycling lorry where she lived. She was seen by neighbours and/or the driver in time. This information about the incident on 23 September 2013 was held on the Police National Database which, presumably, Gloucestershire control and ████████ would have had access to. The concern therefore is in relation to communication between TVP and Gloucestershire Constabulary and, in turn, communication between Gloucestershire Control and its Officers. At Inquest, I did not have available to me details of the specific information passed by TVP control to Gloucestershire control in the early hours which subsequently led to ████████ and his colleague carrying out the welfare check at approximately 03.30. The evidence of ████████ at Inquest was that he did not know that she had been found lying underneath the wheels of the lorry earlier in the morning. He gave evidence that, if he had known this, he would have put in hand arrangements for a MHA assessment. ████████ also gave evidence that he did not know about the previous similar incident on 23 September despite the fact that it was on the PND and, furthermore, on Gloucestershire’s “Unified” Intelligence database. The issue of concern therefore is the fact that specific information, of a high risk nature, was not or may not have been passed by TVP to Gloucestershire Constabulary or, if it was, it may not have been available to ████████. I appreciate that ████████ carried out a prompt welfare check and that Ms Cammell’s presentation was such that ████████ did not consider her to be at risk but it appears he did not have available crucial information. ”
Source location
Suzanne Cammell · 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
Complete a thorough review of the information-sharing concern, consulting senior colleagues across relevant departments.

Verbatim wording from the response
“████████ of our Professional Standards Department has carried out a thorough review of this matter, in the course of which he has consulted with senior colleagues from the Control Room & Enquiries Department, the Force Intelligence Bureau and the Partnership Team (which covers mental health).”

Source location
2014-0579-Response-by-Thames-Valley-Police
Page 1 · response
Published 28 July 2014
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
Thames Valley Police disputes that it failed to inform Gloucestershire Police of the relevant welfare concerns.

Verbatim wording from the response
“In summary, it would seem that TVP informed Gloucestershire Police of the concerns as reported by ████████ insofar as he had found Ms Cammell in a confused state and that she had been trying to get underneath a lorry. Admittedly, the information shared did not go into quite the detail reported by ████████, who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying to get under one. I am not sure whether this would have made a material difference to ████████ risk assessment when he visited Ms Cammell at home. This would seem to be a matter for Gloucestershire but I hope I have at least been able to clarify the information that was shared.”

Source location
2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014
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
Gloucestershire Police was responsible for assessing whether the shared information required a different intervention.

Verbatim wording from the response
“In summary, it would seem that TVP informed Gloucestershire Police of the concerns as reported by ████████ insofar as he had found Ms Cammell in a confused state and that she had been trying to get underneath a lorry. Admittedly, the information shared did not go into quite the detail reported by ████████, who said that he actually woke Ms Cammell while she was under a lorry and not simply that she was trying to get under one. I am not sure whether this would have made a material difference to ████████ risk assessment when he visited Ms Cammell at home. This would seem to be a matter for Gloucestershire but I hope I have at least been able to clarify the information that was shared.”

Source location
2014-0579-Response-by-Thames-Valley-Police
Page 4 · response
Published 28 July 2014
Open published response
24 Jul2014
Inner North London
Concerns raised1
1. Failure to clearly flag direct suicide threats to agencies responsible for housing and eviction
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Graham Darby · 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

Graham Darby, who had alcohol dependence, was found dead at his home the day after being evicted and forcibly re-entering the property; the inquest concluded that the cause of death was suspension by ligature and that his death was a suicide. A significant concern was that a reported threat to take his own life using a knife and rope if evicted was not passed on to the housing agency, and was therefore not sufficiently flagged between agencies.

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 clearly flag direct suicide threats to agencies responsible for housing and eviction
Wider context from the report
“That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction. This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted. The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances. ”
Source location
Graham Darby · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Poor communication within Sussex Partnership Trust and to Brighton & Sussex University Hospital Trust

Concerns raised1

Lack of direct communication between offender managers and hospital clinicians before recall decisions

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.2

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

Concerns raised1

Lack of nationally agreed standard assessment forms for cross-organisational mental health transfers

Concerns raised1

Failure to escalate and notify trolley users of the known cot-side locking risk

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.2

Concerns raised1

Failure of communication between police and hospital staff about missing-person status

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.2

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

Concerns raised1

Lack of dialogue between police and local A&E departments about treatment misunderstandings

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.4

Concerns raised1

Lack of communication between GMP and MEDACS about the existence of an escalation protocol

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

Concerns raised2

Failure of multi-agency communication procedures

Failure of multi-agency communication procedures

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.2

Actions described in response 2

Respondent positions 1

Actions described in response 1

Respondent positions 2

Actions described in response 2

Respondent positions 1

Actions described in response 4

Actions described in response 1

Actions described in response 2