25 Mar 2026 Name not published · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Police training and guidelines requiring updating View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Name not published · 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
A baby died unexpectedly at home on 15 January 2024, after being found unresponsive in a bassinet; chlorpheniramine was present in his blood and had probably been administered by the night nanny. The coroner reached an open conclusion, with expert evidence that the drug could possibly have caused or contributed to the death. Concerns included an inadequate scene examination, failure to seize feeding equipment or search relevant property, insufficient consideration of poisoning, and the lack of specific nanny regulation and guidance about chlorpheniramine.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Police training and guidelines requiring updating
Wider context from the report “4. That police training and guidelines may need to be updated .
” Source location Name not published · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and relaunch the national Investigating Sudden Death in Childhood Course.
Verbatim wording from the response “The College of Policing offers a national, Investigating Sudden Death in Childhood Course, which was reviewed and re-launched in 2025, and which is available to all Home Office forces. The programme has been developed for Lead Investigators who have the responsibility for conducting investigations following the sudden, unexpected death of a child. Those who attending the course should have previously completed Professionalising Investigation Programme (PIP) level 2 or level 3 learning and registration. The course reflects the 2024 National Police Chief’s Council (NPCC) Practice advice on child death investigation and provides delegates with the knowledge to conduct thorough and impartial investigations.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with NPCC colleagues to consider whether further strengthening and alignment of child death investigation practice advice and training is required.
Verbatim wording from the response “While I am satisfied that current police training and practice advice do cover the crucial issues kindly raised. I would also like to reassure you that we will work closely with NPCC colleagues, to consider whether further strengthening of the approach advocated is required. This includes ensuring that both the practice advice and training are aligned in all areas.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise Child Abuse Authorised Professional Practice through a launched consultative process.
Verbatim wording from the response “The College of Policing has recently also launched a consultative period for our revision of Child Abuse Authorised Professional Practice (APP). I will ensure that the team proactively considers whether greater alignment between the practice advice on child death investigations and the APP on child abuse is required.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update MPS child-death investigation policy to reflect NPCC guidance and strengthen expectations for investigative mindset, scene examination, and evidence preservation.
Verbatim wording from the response “After ████████ death, in December 2024, this approach was further reinforced through the introduction of the National Police Chiefs’ Council (NPCC) Practice Advice on Child Death Investigation, which refreshed and strengthened national guidance. The Practice Advice places continued emphasis on professional curiosity, encouraging officers to ask appropriate questions, reflect critically on information received, maintain an open mind, and avoid accepting initial accounts or assumptions at face value. It also provides clearer direction on the conduct of scene examinations, and MPS policy was updated in May 2025 to reflect the key expectations set out within this guidance.” Source location Response from MET
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver specialist sudden-unexpected-child-death investigation training addressing bias, false reassurance, systematic scene examination, forensic opportunities, and toxicological considerations.
Verbatim wording from the response “These expectations have been reinforced through training since May 2025, following implementation of the College of Policing Investigating Sudden Unexpected Death in Childhood programme, which specifically addresses the risk of unconscious bias and the potential for false reassurance when officers encounter a well-presented home or apparently attentive carers. The programme emphasises the importance of maintaining an open and questioning mindset, recognising that neglect, harm, or the administration of harmful substances can occur in any family context. It reinforces the need for systematic scene examination and the preservation of forensic opportunities in all cases, irrespective of initial impressions. Since May 2025, seventy-nine MPS officers have attended this training.” Source location Response from MET
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver seven additional specialist training courses, training eighty-four more MPS officers over the next twelve months.
Verbatim wording from the response “Seven more courses are scheduled to take place over the next twelve months, which will mean an additional eighty-four specialist officers being trained.” Source location Response from MET
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update MPS policy to specifically address poisoning and ingestion of harmful substances in sudden and unexpected child deaths.
Verbatim wording from the response “MPS policy was updated in May 2026 to make specific reference to poisoning and ingestion of harmful substances, reflecting national learning from cases including Daniel Pelka and Arthur Labinjo-Hughes and reinforcing awareness of toxicological considerations in sudden and unexpected child deaths. This change reflects the MPS’s consideration of the Coroner’s observations and supports the ongoing emphasis on early professional curiosity where poisoning or ingestion may be a factor.” Source location Response from MET
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Current police training and practice advice already cover the concerns about child death investigations, so updating them is not currently considered necessary.
Verbatim wording from the response “While I am satisfied that current police training and practice advice do cover the crucial issues kindly raised. I would also like to reassure you that we will work closely with NPCC colleagues, to consider whether further strengthening of the approach advocated is required. This includes ensuring that both the practice advice and training are aligned in all areas.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for leading a national review may more appropriately rest with the NPCC Homicide Working Group’s Child Deaths Sub-Group.
Verbatim wording from the response “The NCA respectfully submits that the responsibility for leading a review may more appropriately rest with the NPCC Homicide Working Group (Child Deaths Sub-Group). This group (led by ████████ Nottinghamshire Police, for the NPCC) leads national guidance on child death investigations and is a multi-agency group which includes the NCA who, via FMAT, feed data from Op Marshall into the group. FMAT forwarded the Prevention of Death’s report to the group’s chair on the 21st April and if the Coroner wishes to make any enquiries of this group, it can be contacted at ████████” Source location Response from NCA
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Updated national guidance, policy amendments and ongoing training address concerns about investigating sudden and unexpected child deaths.
Verbatim wording from the response “Since that time, national guidance and learning have developed. The introduction of the NPCC Practice Advice on Child Death Investigation (December 2024) refreshed and strengthened expectations around initial investigative mindset, scene examination, seizure of relevant items, consideration of toxicology and the risk of bias arising from early impressions of the home environment or caregivers. In response, MPS policy has been reviewed and updated to reflect this updated national guidance, including clearer reference to poisoning and ingestion of harmful substances and enhanced direction on the handling of feeding equipment and other potential evidential material.” Source location Response from MET
Open published response
7 Oct 2025 Ann Sabrina LASKOWSKY · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 1
Lack of specific policy, guidance or training on using the Partner Triage Line View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ann Sabrina LASKOWSKY · 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
Ann Sabrina Laskowsky was found unresponsive at home on 5 October 2024 after police attended when an inactivity alarm was triggered. She was taken to hospital later that day and died on 6 October 2024 from naturally occurring disease contributed to by self-neglect and exacerbated by longstanding alcohol dependence. The principal concerns were the adequacy and clarity of police first-aid training, including recognising abnormal breathing and unresponsiveness, and officers’ knowledge, use and training regarding the Partner Triage Line.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of specific policy, guidance or training on using the Partner Triage Line
Wider context from the report “2. The knowledge, use and training in respect of available resources
In the course of the Inquest, I heard evidence in respect of a resource or service, known as the ’Partner Triage Line’. This is a service which has been provided for a number of years by the Yorkshire Ambulance Service which provides a direct line for police officers to speak to a medical practitioner at the emergency operations centre, to seek advice, with the facility for the Officer to send photographs to the practitioner to help inform their advice and an ability for the practitioner to conduct a live video assessment.
Differing evidence was heard at inquest in terms of the knowledge of individual officers in respect of that service, with one officer being unaware that there was a service or resource.
In the course of my investigation, I received further evidence confirming that the telephone number for the ‘Partner Triage Line’ is visible and accessible in the contact environment and is then sent to officers on request, but that it is not known or promoted to those officers carrying out operational duties, who are those who are likely to need it the most.
I have significant concerns in relation to the knowledge of this valuable resource and its overall lack of use and promotion amongst those Officer who might need it the most. In particular my concerns relate to the following:-
a. The lack of knowledge and use of the service throughout West Yorkshire Police given the lack of dissemination and promotion amongst all of the officers to whom it would be of benefit, providing them with the tools to enable them to properly and effectively carry out their duties; and
b. The lack of specific policy, guidance or training for Officers in respect of how the service can be used to support them in carrying out their duties , enabling them to keep members of the public safe. This is of particular concern, given that the service has now been available for a number of years.
” Source location Ann Sabrina LASKOWSKY · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind officers during initial and annual refresher first aid training that they can use the YAS Partner Triage Line.
Verbatim wording from the response “Finally, Trainers will remind officers whilst on their First Aid Training Courses (including yearly refresher courses) that they can utilise the YAS Partner Triage Line if they need advice from a clinically trained practitioner.” Source location Response from West Yorkshire Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Post an intranet briefing, update operational briefings and training materials, and provide force-wide intranet access to the Partner Triage Line information.
Verbatim wording from the response “Following the conclusion of the inquest into Ann’s death an intranet briefing has been posted to remind everyone of the facility and details of the facility have been included in operational briefings and training and guidance material has been updated to include reference to the Partner Triage Line, which all members have the force have access to via the force intranet. The Right Care Right Person team have been tasked with monitoring the usage of the facility as part of our partnership work with YAS.” Source location Response from West Yorkshire Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational deployment of local clinical support tools falls outside the FALP licensing framework.
Verbatim wording from the response “The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Individual forces, working with local healthcare providers, determine the operational deployment of local clinical support tools.
Verbatim wording from the response “The operational deployment of local clinical support tools, such as the Partner Triage Line, is determined by individual forces in collaboration with local healthcare providers and falls outside the scope of the FALP licensing framework. Nonetheless, the College recognises the critical importance of ensuring that learning from incidents involving first aid provision is captured and shared across the policing community.” Source location Response from College of Policing
Open published response
Concerns raised 1
Lack of clear and consistent guidance and training on timing and factors for announcing “armed police” during containment and call-out operations View source
This report raised 2 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.
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AI-generated summary
SEAN FITZGERALD · 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 4 January 2019 in Coventry, Sean Fitzgerald emerged from the rear door of a house during a West Midlands Police firearms operation and was shot in the chest by a police firearms officer. He died at 6.55pm despite first aid and medical treatment. The report identifies concerns about inconsistent guidance and training on when to announce “armed police” and how firearms officers should position themselves near property entrances, including the risks associated with close proximity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of clear and consistent guidance and training on timing and factors for announcing “armed police” during containment and call-out operations
Wider context from the report “(1) Training and practice in relation to timing of any announcement of “armed police” in police firearms operations involving containment of properties
In the police operation in which Mr Fitzgerald was killed, the officers employed the tactic of “contain and call out with limited entry.” This involves firearms officers “containing” a property by surrounding it and providing firearms cover with their weapons; creating a breach by forcing entry; and “calling out” the subjects inside (directing them to leave through the point of breach), without the officers themselves entering. In evidence, it was explained that this is a very common tactic, which is used in a range of scenarios.
████████ a former senior firearms officer and armed policing lead within the College of Policing, gave evidence in the inquest. He explained that an integral part of the tactic is for officers to announce their presence by loud shouts of “armed police.” This warns those inside the property that it is the police forcing entry and informs them that the officers are armed. It was explained that this warning helps to avoid confusion and encourage compliance, thereby reducing the risk of harm to officers and occupants. The timing of the announcement is plainly important, and any potential for confusion or for making the announcement at the wrong time risks fatal consequences.
████████ said that the timing of any such announcement is not prescribed by national training or guidance, and that there is no “template” for when it should be done , although he understood that it would usually be made after achieving a breach (e.g. breaking down a door). The procedural and training documents (both national and from WMP) which were put in evidence in the inquest gave no detailed guidance on the subject . The Chief Firearms Instructor at WMP, ████████, gave evidence that WMP trains its officers to make the announcement after achieving a breach.
The evidence of the officers involved in the operation as to the recommended or standard practice was inconsistent. The Strategic Firearms Commander said that he expected officers to announce themselves as armed police as soon as they were in position. The Operational Firearms Commander said that the shout should first be made as soon as the chainsaw was being applied to the door and again as the breach was made. One further member of the team said that he thought best practice was to give the shout as the chainsaw was being applied, but acknowledged that he had not done so on this occasion. Several other members of the team thought that proper practice was only to make the announcement after the door had been breached.
The firearms briefing told the officers that method of entry would be conducted and “[o]nce breached, challenges will be made at the threshold and suspects will be handcuffed”. There was no further discussion or direction about when the officers should first announce their presence.
In the event, the officers at the front of the property did not shout “armed police” before breaking down the two doors at the front of the property. Before any announcement was made, Mr Fitzgerald left through the rear door of the premises and was shot by Officer K, who was providing rear containment.
In these circumstances, I am concerned that the guidance and training given to firearms officers on tactics of containing and entering properties (and specifically in relation to the containment and call out with limited entry tactic) does not ensure a clear and consistent understanding of when they should announce their presence, or what factors to consider in deciding when to make the announcement . I am also concerned that the topic was not the subject of more specific discussion or direction in the briefing.
It is important that officers conducting these kinds of highly challenging firearms operation should have proper guidance on this subject. If the approach of different officers is inconsistent, there is the clear potential for mistakes to be made and for the lives of officers and others to be put at risk. I appreciate that expert firearms training officers are best placed to produce any further guidance, and that it may not be possible to have a hard and fast rule. However, the inconsistent views of highly trained officers which were given in this inquest indicate that the subject ought to be further addressed in training and in formal guidance.
” Source location SEAN FITZGERALD · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Draft additional guidance for inclusion in authorised professional practice on armed policing and post-incident procedures.
Verbatim wording from the response “Following consultation with stakeholders, most notably the Independent Office of Police Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter, additional guidance has been drafted for inclusion within The College authorised professional practice on armed policing (APP-AP) and the authorised professional practice on post-incident procedures following death or serious injury. The amended APP will be published within the next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’ Council (NPCC) national circular and circulated to all police forces in the UK for immediate implementation. The amended guidance has been included in a practical scenario that formed the basis of this year’s annual College national Post Incident Manager (PIM) training which all PIMs must receive.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the amended authorised professional practice guidance within the stated two-to-three-week timeframe.
Verbatim wording from the response “Following consultation with stakeholders, most notably the Independent Office of Police Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter, additional guidance has been drafted for inclusion within The College authorised professional practice on armed policing (APP-AP) and the authorised professional practice on post-incident procedures following death or serious injury. The amended APP will be published within the next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’ Council (NPCC) national circular and circulated to all police forces in the UK for immediate implementation. The amended guidance has been included in a practical scenario that formed the basis of this year’s annual College national Post Incident Manager (PIM) training which all PIMs must receive.” Source location Response from College of Policing
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the interim guidance in an NPCC national circular and circulate it to all UK police forces for immediate implementation.
Verbatim wording from the response “Following consultation with stakeholders, most notably the Independent Office of Police Conduct (IOPC), who were also in receipt of a letter of concern regarding the same matter, additional guidance has been drafted for inclusion within The College authorised professional practice on armed policing (APP-AP) and the authorised professional practice on post-incident procedures following death or serious injury. The amended APP will be published within the next 2-3 weeks and in the interim the guidance has been published in a National Police Chiefs’ Council (NPCC) national circular and circulated to all police forces in the UK for immediate implementation. The amended guidance has been included in a practical scenario that formed the basis of this year’s annual College national Post Incident Manager (PIM) training which all PIMs must receive.” Source location Response from College of Policing
Open published response
Concerns raised 1
Lack of mandatory or refresher police officer training in constant observations View source
This report raised 8 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.
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AI-generated summary
Matthew Terrill · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of mandatory or refresher police officer training in constant observations
Wider context from the report “4. Lack of refresher or mandatory annual training for police officers in relation to constant observations.
I am told that there is no specific mandatory training for police officers on constant observations , but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I have been told that there is an optional CPD module available to officers on constant observation training. I am concerned that police officers are being regularly asked to perform constant observations on detainees of the highest risk levels without any mandatory training or refresher training on the subject . Whilst the Custody Sergeant is tasked with providing a briefing to officers who are tasked with constant observations, I am concerned that there is no evidence of consistency in this task being completed to an appropriate standard or at all. There is a risk that in a busy custody suite, this briefing will be overlooked or omitted (and in fact that was the evidence in this case). There is no evidence to reassure me that this was a one-off incident, rather the evidence before me suggested that it was not. This gives rise to a risk of future death for detained persons on level 4 constant observation.
” Source location Matthew Terrill · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver scenario-based training on Acute Behavioural Disturbance, positional asphyxia, safer restraint and continuous observation of restrained subjects.
Verbatim wording from the response “The PST delivery for this year commencing in April 2024 is all scenario-based delivery. There are six different scenarios mandated by the College of Policing. One scenario is based on ‘vulnerable person.’ The Trainers can introduce ABD by slightly adapting the vulnerable person scenario, to having the role player displaying some of the signs and symptoms of ABD, with the trainer also providing input to the role player to display varying signs and symptoms of ABD such as, the person is hot to touch, incredibly strong or sweating heavily etc. From this the student should realise that they are dealing with someone who is having an ABD episode and deal with them accordingly.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
12 Jan 2021 Cherylan CLULOW · Prevention of Future Deaths report Dorset
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Concerns raised 1
Lack of training and dissemination of information on obtaining fire drop keys View source
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.
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AI-generated summary
Cherylan CLULOW · Prevention of Future Deaths report
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Report summary
Cherylan Clulow was found semi-conscious at home after police were initially unable to gain access beyond the communal door, and she died in hospital on 30 August 2019 following extensive and multiple strokes. The substantive concerns related to delays in accessing shared accommodation during emergencies, including the lack of formal information, training, and general distribution of fire drop keys or key fobs to police officers.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of training and dissemination of information on obtaining fire drop keys
Wider context from the report “(1) The Police Officers who were tasked with the initial attendance could not gain access beyond the communal doors.
(2) The Police Officers did not believe it was proportionate (based on the information which they had) to force entry through the communal doors which required specialist input. They were aware that a colleague had purchased for himself a fire drop key (to be used in emergency situations which could be used to override the communal lock door. There was a delay in gaining access to the address of the deceased.
(3) The Police Officers had no formal information as to where they could source a fire drop key. There was no knowledge of formal steps to be taken to access to a fire drop key particularly as access to communal properties is that more difficult to gain.
(4) There appears to be no general distribution of such keys or key fobs to Dorset Police Officers in order to gain access to shared accommodation by officers in an emergency situation 24 hours a day, 365 days per year.
(5) There appears to be no training or dissemination of information as to how such keys can be obtained.
” Source location Cherylan CLULOW · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Identify vulnerable residents in privately owned communal premises, obtain relevant keys and fobs, and store access arrangements locally with linked incident-management instructions.
Verbatim wording from the response “To compensate for this, we are in the process of identifying specific vulnerable individuals who live in similar but privately-owned communal premises, with a view to obtaining the relevant keys and fobs to facilitate access to those specific properties where required. Due to the volume of such items, where privately-owned premises are concerned we will store the relevant keys and fobs in a police station local to the address in question, and link instructions for obtaining the relevant item to the record that we hold for the vulnerable individual in question on our police incident management system.” Source location 2021-0009-Response-from-Dorset-Police-Redacted
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27 Nov 2020 Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report Inner North London
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Concerns raised 1
Confusion among police officers about how Merlin recording should work in practice View source
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.
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AI-generated summary
Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Confusion among police officers about how Merlin recording should work in practice
Wider context from the report “6. The police officer giving evidence was aware of the view of the Directorate of Professional Standards (DPS) regarding the failure to create a Merlin, expressed in its report on the police handling of the incident on 8 July, but he seemed very confused about how that should work in practice .
If he is confused, even after police have taken him through the DPS report, then other police officers may also be confused.
” Source location Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a Merlin Toolkit advising officers when to complete reports and requiring Vulnerability Assessment Framework-based risk assessment.
Verbatim wording from the response “The MPS will shortly be introducing a Merlin Toolkit, which will provide advice and guidance on the circumstances in which reports should be completed. This also references the Vulnerability Assessment Framework (VAF) which should be used as the basis for assessment for all officers. This assessment is based on appearance, behaviour, communication/capacity of the victim and whether the victim is in danger and the environment/circumstances they are in. The MPS considers that this action will support officers in making appropriate decisions in respect of completing Merlin Reports for vulnerable people.” Source location 2020-0255-Letter-from-Metropolitan-Police-Redacted.pdf
Open published response
Concerns raised 1
Lack of mandatory refresher training for police officers on mental health, learning disability and autistic spectrum disorder View source
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.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Ewan Nathanial Brown · 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
Ewan Nathanial Brown was found dead on 30 April 2019 after absconding while awaiting mental health assessment, following concerns about his behaviour and mental health. The inquest concluded that he died by accidental drowning while experiencing an unassessed and untreated psychotic illness. Concerns included gaps in police and health-service information sharing, multiagency coordination, mental health training, and family contact during the missing-person search.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of mandatory refresher training for police officers on mental health, learning disability and autistic spectrum disorder
Wider context from the report “3. There is no mandatory refresher training for Police Officers in relation to mental health issues, learning disability and autistic spectrum disorder . After their initial training, when officers join the Police Force, such further training is optional but not compulsory . Given the prevalence of mental health issues in society and the complexities of dealing with such issues for officers of all ranks and across all areas of policing, this is an issue that all officers would benefit from at regular intervals.
” Source location Ewan Nathanial Brown · Prevention of Future Deaths report
Open source report
9 Jul 2019 Leroy Dacosta Junior Medford · Prevention of Future Deaths report Berkshire
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Concerns raised 5
Insufficient protected training time for police officers View source Failure to safely prioritise the volume and frequency of police training updates View source Failure to monitor whether police training has been taken up View source
Failure to encourage officers to consult infrequently used SOPs and guidance View source Failure of the police training system to disseminate training effectively and safely View source See 2 more concerns
This report raised 2 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.
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AI-generated summary
Leroy Dacosta Junior Medford · 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
Leroy Dacosta Junior Medford, referred to as Junior, was arrested by Thames Valley Police on 1 April 2017 and detained under the drugs SOP after being suspected of concealing drugs. His condition deteriorated in his cell, and resuscitation was unsuccessful; the recorded cause of death was heroin (diamorphine) toxicity. The principal concerns were that officers of all ranks involved did not know that the SOP required observation from inside the cell, and broader concerns about how police training is delivered, monitored, prioritised and taken up.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient protected training time for police officers
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this . Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” Source location Leroy Dacosta Junior Medford · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to safely prioritise the volume and frequency of police training updates
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised . There is perhaps a risk of lack of urgency if training updates are given too frequently .
” Source location Leroy Dacosta Junior Medford · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to monitor whether police training has been taken up
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up , and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” Source location Leroy Dacosta Junior Medford · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to encourage officers to consult infrequently used SOPs and guidance
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service. I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe.
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly .
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” Source location Leroy Dacosta Junior Medford · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of the police training system to disseminate training effectively and safely
Wider context from the report “Concern Regarding Future Training
My concern is a broader one – around how training is disseminated and monitored within the police service . I am satisfied that this is an issue that does not only relate to Thames Valley Police.
We heard that the police, like many services and professions, are given regular updates and training, in various formats. It is reasonable to suggest that different people learn in different ways. What this case has illustrated however, is that the current system is not effective or safe .
That may be partly because of the pressures on the service. It may be that officers are not given sufficient protected training time to do this. Training is given in many, varied ways. Much of this is on-line.
I consider that there should be a national review and debate about the way in which training is delivered to police officers across the country. There should be consideration given to how police forces reassure themselves that training has not just been offered, but has been taken up, and that officers are encouraged to consult SOPs and other guidance that they do not use regularly.
This would of course require easy access, digitally, to these procedures and efficient updating and storage of these policies for officers to review.
It is a matter for the respondents to this letter to consider the volume of training issued to police officers, and whether this can be safely prioritised. There is perhaps a risk of lack of urgency if training updates are given too frequently.
” Source location Leroy Dacosta Junior Medford · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the prevention of future deaths report and response with chief constables across all forces.
Verbatim wording from the response “It appears from the response from the Chief Constable of Thames Valley Police that the force has taken the points you raise very seriously, and have taken steps locally to address your concerns. But this case has clearly highlighted the need to ensure that individual chief constables pay particular attention to the way in which training is delivered within their own force, its method, frequency and participation levels. I have therefore shared your report and this response with chief constable colleagues in all forces across the country, in case there are areas of practice within their own force which they feel may benefit from review.” Source location 2019-0233-Response-by-NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide recorded custody-sergeant briefings to officers deployed on cell watch.
Verbatim wording from the response “○ Officers working on a cell watch deployment now receive a specific briefing from the custody sergeant. This is recorded once received and to improve standardisation and to avoid any essence of doubt, TVP are now creating a video clip to be played to all officers on cell watch for those on the drugs protocol providing a visible representation of how to use the drugs toilet appropriately and how best to conduct such close watch on a detained person. We believe this is the first time this methodology has been used in the country.” Source location 2019-0233-Response-by-Thames-Valley-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Local Police Area points of contact to communicate new guidance and encourage staff review.
Verbatim wording from the response “It is accepted that TVP have had challenges to communicate with all front line staff to ensure they are aware of guidance and update themselves on it, especially when they are performing an unfamiliar role. To counter this the Policing Strategy Unit have introduced Special Points of Contact or ‘SPOCs’ from within the team on each Local Police Area so they can build relationships with local staff. This will assist with communications locally when new guidance is produced so staff are aware of its existence and are encouraged to review it.” Source location 2019-0233-Response-by-Thames-Valley-Police
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Participate in the College of Policing’s development of a national strategy for police learning.
Verbatim wording from the response “As Chair of the National Police Chiefs’ Council, it is my role to ensure that chief constables work together collaboratively in the national interest, although that does not extend to directing chief constables to take a specific course of action. I have, however, discussed this matter with the NPCC’s national lead for training and development, Mark Milton, Director of People and Organisational Development at Avon and Somerset Constabulary. Mark has carefully considered your recommendations, and reviewed the responses of both Thames Valley Police and the College of Policing. Mark has advised me that on behalf of the NPCC, he is closely involved in the College of Policing’s work on a national strategy for police learning, which I know the College of Policing have described to you in their response to your recommendations, so I won’t repeat the detail here.” Source location 2019-0233-Response-by-NPCC
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a video briefing demonstrating appropriate drugs-toilet use and close observation of detainees on the drugs protocol.
Verbatim wording from the response “○ Officers working on a cell watch deployment now receive a specific briefing from the custody sergeant. This is recorded once received and to improve standardisation and to avoid any essence of doubt, TVP are now creating a video clip to be played to all officers on cell watch for those on the drugs protocol providing a visible representation of how to use the drugs toilet appropriately and how best to conduct such close watch on a detained person. We believe this is the first time this methodology has been used in the country.” Source location 2019-0233-Response-by-Thames-Valley-Police
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Chief constables are responsible for deciding and delivering training volume, methods, prioritisation and participation within their own police forces.
Verbatim wording from the response “Each chief constable is therefore ultimately responsible for the delivery of training in their police force, which includes making decisions about the volume and method of training, the way in which different training is prioritised according to local need and any issues around levels of participation. This is by no means straightforward; you will appreciate the vast number of important areas of policing practice in which officers and staff require training, which is of course costly, and usually necessitates the abstraction of officers from their regular duties. Chief constables are therefore faced with many competing priorities which must all be carefully balanced so as not to adversely impact upon the service they provide.” Source location 2019-0233-Response-by-NPCC
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The NPCC Chair’s role does not include directing chief constables to adopt a specific training course of action.
Verbatim wording from the response “As Chair of the National Police Chiefs’ Council, it is my role to ensure that chief constables work together collaboratively in the national interest, although that does not extend to directing chief constables to take a specific course of action. I have, however, discussed this matter with the NPCC’s national lead for training and development, Mark Milton, Director of People and Organisational Development at Avon and Somerset Constabulary. Mark has carefully considered your recommendations, and reviewed the responses of both Thames Valley Police and the College of Policing. Mark has advised me that on behalf of the NPCC, he is closely involved in the College of Policing’s work on a national strategy for police learning, which I know the College of Policing have described to you in their response to your recommendations, so I won’t repeat the detail here.” Source location 2019-0233-Response-by-NPCC
Open published response
28 Jun 2017 Olaseni Lewis · Prevention of Future Deaths report South London
View report summary
Concerns raised 1
Lack of guidance and training for failure to achieve control within a given period View source
This report raised 7 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.
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AI-generated summary
Olaseni Lewis · 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
Olaseni Lewis developed an acute psychotic illness, was admitted to hospital, and was later restrained by police and healthcare staff after becoming agitated. He became unconscious and suffered a cardiac arrest. The concerns included prolonged and disproportionate restraint, inadequate police and healthcare training and communication, unclear responsibilities, and failures to respond appropriately to the medical emergency.
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 and training for failure to achieve control within a given period
Wider context from the report “(4) Police officers were given no advice or training what they could or should do if control was not achieved within a given period of time .
” Source location Olaseni Lewis · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing training and prompt medical intervention are considered sufficient when officers fail to achieve control within a specified period.
Verbatim wording from the response “4. As outlined above at 3, the advice received from IMSAP is that the attachment of any specified time value to the term “prolonged” would be without a clinical basis. Suggestions during the inquest in relation to the option of leaving Mr. Lewis in mechanical restraints only (i.e. handcuffs and leg restraint) were not supported by the expert evidence, as it would not have removed the basis for resistance/struggling and therefore would not have reduced the risk to life. Police training in respect of all suspected incidents of ABD is clear, consistent and unambiguous. Officers should treat all suspected incidents of ABD as a medical emergency. The emphasis is then on obtaining appropriate and timely medical intervention, whether from LAS or other health partners.” Source location 2017-0205-Response-by-Metropolitan-Police
Open published response
Concerns raised 1
Lack of guidance on deploying PAVA spray when a detainee is believed to have placed something in their mouth View source
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.
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AI-generated summary
Darran Hunt · 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 8 February 2015, Darran Hunt was involved in a struggle with police after attempting to evade detention and placing a package in his mouth. He choked on the package and died despite efforts to clear his airway and provide life support. The report raises concerns about police training and guidance on using PAVA spray, forced searches of a detainee’s mouth, and control and restraint where a detainee has placed something in their mouth.
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 on deploying PAVA spray when a detainee is believed to have placed something in their mouth
Wider context from the report “1. Use of PAVA Spray
It has been suggested by the expert during the course of the Inquest that “luck” will determine whether a person sprayed with PAVA spray will inhale or exhale at the point immediately after being sprayed. There is clearly a risk therefore that a person with an object in their mouth could choke on that item if they inhale immediately upon being sprayed. At present there does not appear to be any guidance for officers on whether they should use PAVA spray in the circumstances of this case . Consideration needs to be given to whether guidance/policy should be issued to officers about if and when PAVA spray should ever be deployed in respect of a detainee who is believed to have placed something in their mouth.
” Source location Darran Hunt · Prevention of Future Deaths report
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Includes failures in police arrangements for prioritising, delivering, updating, monitoring uptake of and assuring understanding of required training and operational guidance, including refresher training, protected training time, digital access to SOPs, guidance familiarisation and checks that officers have completed or understood relevant updates.
