Recurring concern

Unreliable police-custody risk assessment processes

Pin Get email alerts Request correction

First reported 3 Mar 2014•Latest report 12 Aug 2024

Definition

What this concern includes

Includes failures in police-custody risk-assessment arrangements, including clear guidance for custody sergeants, completion when custody is accepted, reassessment when circumstances change, and timely transfer of the assessment or its risk information to escorting or receiving custody staff before movement.

Not included

  • Excludes prison-only, probation or post-release risk assessments where police custody is not the bounded setting.
  • Excludes generic custody-record deficiencies unless they directly prevent completion, use or transfer of a police-custody risk assessment.
  • Excludes clinical or mental-health risk assessments unless they are explicitly part of the police-custody risk-assessment process.
  • Excludes failures occurring after a complete and timely police-custody risk assessment has been made available, including downstream escort or healthcare decisions.
Reports
6

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
7

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Metropolitan Police Service3
Association of Ambulance Chief Executives1
College of Policing1
Department of Health and Social Care1
Dorset Police1
Dorset & Wiltshire Fire and Rescue Service1
HM Prison and Probation Service1
Independent Office for Police Conduct1
Maritime and Coastguard Agency1
Midlands Partnership University NHS Foundation Trust1
National Fire Chiefs Council1
National Police Air Service1
National Police Chiefs’ Council1
NHS England1
Niche Technology UK Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Black Country

    AI-generated summary

    Mr Parminder Singh Sanghera · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Parminder Singh Sanghera was arrested after displaying erratic behaviour, including running naked, and was taken to hospital before being held in police custody. He was released without charge on 13 February 2023 and was later found deceased in a canal near the custody suite. The principal concern was that, despite his behaviour and vulnerability, no full mental health assessment was undertaken before his release and risk assessments did not identify a risk of suicide or self-harm.

    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 hospital and police custody risk assessments to identify suicide or self-harm risk before release

    Wider context from the report

    “1. During the course of the inquest, I heard evidence Mr Sanghera was deemed to be suffering from behavioural issues rather than a mental health crisis and no full Mental Health Act assessment took place either at New Cross Hospital or whilst in custody at Oldbury Police station. 2. The risk assessments performed in hospital and police custody identified no concerns of risk of suicide or self-harm from release. However, evidence at the inquest showed that he was suffering from a mental health crisis at the time. 3. My concern is that given the erratic behaviour he was displaying and his vulnerability, further consideration should have been given for a full mental health act assessment to take place before release. Therefore, you may wish to consider reviewing the arrangements and assessments required before discharge from hospital or being released from custody. ”

    Source location

    Mr Parminder Singh Sanghera · 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

    Audit pre-release risk assessments monthly to monitor and improve their quality.

    Verbatim wording from the response

    “(i) Over 90% of custody staff have completed the College of Policing vulnerability in custody training; (ii) Pre-release risk assessments are now subject to monthly audits to ensure quality; (iii) Detained persons now receive a leaflet signposting to support service pathways, a copy of which is enclosed with this response; (iv) The Health Care Provider specification now includes a requirement for their staff to have access to Summary Care Records (Mitie became the service provider on 1 September 2024 and have access to these records, whereas the previous provider did not). When the name, date of birth and address of the detained person is entered the Summary Care Records entry would provide an NHS number, GP details and potentially a pharmacy number.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 30 September 2024

    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

    Mental-health input for people in police custody is provided through the locally organised Liaison and Diversion Service between police and mental-health services.

    Verbatim wording from the response

    “Further, on the latter attendance the 12th February, the Trust does not provide any mental health “input” in relation to those in police custody. It is understood that this would be provided by the Liaison and Diversion Service – which will be organised at a local level between the police and mental health services and is subject to a Memorandum of Understanding between services. Again, this is not something that the Trust would have any involvement in.”

    Source location

    Response from Wolverhampton NHS Trust
    Page 2 · response
    Published 30 September 2024

    Open published response
  2. Dorset

    AI-generated summary

    Ivan Rumenov Ignatov · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ivan Rumenov Ignatov entered the English Channel on 19 July 2020 and did not resurface; he was found deceased in the water on 31 July 2020. The report raises concerns about police risk assessment and recording, support for detainees released without accommodation or with language and literacy barriers, and communication between emergency and search-and-rescue services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient guidance for custody sergeants assessing detainee risk

    Wider context from the report

    “ii. There is not sufficient guidance given to custody sergeants on a national basis of how to assess a person’s risk. ”

    Source location

    Ivan Rumenov Ignatov · 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

    Remind custody staff through a News Bulletin about the 12 factors indicating increased risk.

    Verbatim wording from the response

    “Additionally, it is our intention to remind Custody Staff of the 12 factors indicating increased risk (as featured in the College of Policing Authorised Professional Practice - in relation to detention and custody risk assessment) by way of News Bulletin, and will then be reviewing, that due consideration is being given to these factors by Custody Staff, by way of dip sampling, as a part of our culture of continuous improvement within the Dorset Police Custody hierarchy.”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add a first-time-in-police-custody question to the APP risk-assessment checklist.

    Verbatim wording from the response

    “1. No set Risk Assessment question re first time in custody on the Niche/RMS custody record application or in APP.”

    Source location

    Response from College of Policing
    Page 1 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Notify police forces when the amended risk-assessment checklist is issued.

    Verbatim wording from the response

    “The checklist sets out the questions which custody officers must ask when assessing detainees. Once this amendment has been made the College will write to forces informing them of the change. We are aware that many force’s custody systems are embedded within a wider records management systems and may take some time to update their systems.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide national risk-assessment principles addressing professional judgement and uncertainty in custody risk assessment.

    Verbatim wording from the response

    “There is very limited evidence on the effectiveness of risk assessment tools. These tools are designed to assist professional judgement. The College has produced risk assessment principles that give strong and consistent messages about assessing risk. The first of the ten principles makes clear that risk assessing is not a certain process and that assessors make decisions in situations of considerable uncertainty. Principle three makes clear that risk assessing is a matter of judgement and balance. Principle four states that harm can never be totally prevented. The ten risk principles, taken together, give comprehensive guidance on how to carry out risk assessment.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    National guidance on custody risk assessment will be addressed by the College of Policing rather than Dorset Police.

    Verbatim wording from the response

    “In preparing this response, we have been in contact with the College of Policing (who have also received the Regulation 28 report) and, on the basis that this is a National issue, they have indicated to us that they will be addressing this concern with you directly in their response to the Report.”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Many concerns in the report fall outside NHS England’s remit, so it can comment only on matters relevant to its functions.

    Verbatim wording from the response

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

    Source location

    Response from NHS England
    Page 1 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Dorset Police are better placed to respond to many concerns addressed to multiple parties involved in the case.

    Verbatim wording from the response

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

    Source location

    Response from NHS England
    Page 1 · response
    Published 12 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing professional-judgement arrangements are considered sufficient for assessing and managing custody risks; categorical high, medium and low grades are not needed.

    Verbatim wording from the response

    “There is very limited evidence on the effectiveness of risk assessment tools. These tools are designed to assist professional judgement. The College has produced risk assessment principles that give strong and consistent messages about assessing risk. The first of the ten principles makes clear that risk assessing is not a certain process and that assessors make decisions in situations of considerable uncertainty. Principle three makes clear that risk assessing is a matter of judgement and balance. Principle four states that harm can never be totally prevented. The ten risk principles, taken together, give comprehensive guidance on how to carry out risk assessment.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 12 June 2023

    Open published response
  3. Inner South London

    AI-generated summary

    Mr Ian McDonald Taylor · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct and record an adequate ongoing risk assessment

    Wider context from the report

    “Whilst PC ████████ was away from Mr ████████ he accepts that he is heard shortly after 18.14 stating to his sergeant on the radio “He’s currently on the floor playing the whole poor me poor me; he’s going to have to go to hospital though as a matter of course.” And at 18.24: “He’s saying he has chest pains he cant breathe blah blah; it’s a load of nonsense but there we go” He said in court that he formed these views as Mr Taylor seemed iller than he would expect from the nature of the previous altercation. He denied he thought Mr Taylor was faking. He claims to have made a continual risk assessment, but there is no record or evidence of that. He said that his views were influenced by a previous incident in which a man sprang to violence from previous calmness. They were not his final conclusion. There was no evidence as to his forming a different conclusion in the following 8 minutes before the cardiac arrest. ”

    Source location

    Mr Ian McDonald Taylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. East London

    AI-generated summary

    Mr Valdas Jasiunas · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Valdas Jasiunas, who had serious underlying health problems including chronic alcohol liver disease and seizures, was arrested and held in police custody on 1 September 2010. He collapsed in his cell the following morning and died in hospital on 2 September 2010. Concerns included the identification and management of alcohol dependency, erroneous custody-record entries that could provide false reassurance, and communication difficulties where English was not the detainee’s first language.

    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 a specific alcohol-dependency question in custody-suite risk assessments

    Wider context from the report

    “1. It was noted that staff in custody suites have to deal with a large number of detained persons who suffer from alcohol dependency. The risks of withdrawal to those who are alcohol dependent are wide ranging from shakes and tremors to death. In light of the frequency of dealing with detained persons who suffer from alcohol dependency and in light of the severity of the potential risk, it was considered that a specific question in the risk assessment document as to dependency on alcohol should be included. The current risk assessment simply states “are you dependent on drugs or any other substance”. A directly pointed question relating to alcohol is likely to be of greater assistance in ensuring that the risk is clearly identified, assessed and managed. ”

    Source location

    Mr Valdas Jasiunas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. South Yorkshire (Western)

    AI-generated summary

    Neil Budziszewski · 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

    Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

    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

    Incomplete risk-assessment questions and documentation

    Wider context from the report

    “(3) The risk assessment completion at Bridge Street did not include asking Mr Budziszewski if he wanted to see a doctor, if he was on medication or if he was in contact with a medical service. Nor did it document that Mr Budziszewski should be checked every 30 minutes. ”

    Source location

    Neil Budziszewski · 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 to open custody records and complete risk assessments

    Wider context from the report

    “(1) When Mr Budziszewski was first presented to the Ecclesfield afternoon shift custody sergeant he accepted custody without opening a custody record or completing a risk assessment. Whilst it is accepted that Mr Budziszewski was in drink at the time and un-cooperative there appears to have been no thought given to a risk assessment. ”

    Source location

    Neil Budziszewski · 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 to reconsider risk assessments when detainee cooperation improves

    Wider context from the report

    “(4) The custody sergeant at Bridge Street gave evidence that he was unable to conduct a full risk assessment because of Mr Budziszewski‘s ‘lack of compliance. However, no arrangement was made for the risk assessment to be reconsidered at a time when Mr Budziszewski was more compliant (which happened quite shortly thereafter). This officer recognised that an alcoholic who was approaching sobriety is someone who needs to be seen by a health care professional. ”

    Source location

    Neil Budziszewski · 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

    Highlight custody-record and risk-assessment requirements in custody training and remind current staff through briefing and rotational training.

    Verbatim wording from the response

    “It is a basic requirement that anyone entering a custody suite should be assigned a custody record and a risk assessment should be completed. This should be done even where the detainee is un-cooperative. This is something which is covered by PACE Code C which is covered in the training provided to custody officers. Having spoken to a sample of custody sergeants during April 2015 an uncooperative detainee under the influence of alcohol is a regular occurrence in custody and a custody record is still routinely opened and a risk assessment completed on the information available and updated in due course. In the future this point will be highlighted in the training and all current staff will be reminded of this requirement by the end of May 2015 by way of briefing document from the Inspectors and rotational training commencing 21 May 2015.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 1 · response
    Published 23 March 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

    Implement digital custody records requiring electronic recording of checks, observations, assessments and associated audit times.

    Verbatim wording from the response

    “It is accepted that Mr Budziszewski should have been on 30 minute rousing checks and that this should have been annotated on the custody record when the checks were undertaken. South Yorkshire police have now moved to fully digital custody records and each check will have to be placed onto the electronic custody record. This system has been in place since 17 February 2015 and it is mandated that the checks have to be carried out. The appropriate checks are preselected in a drop down menu on the electronic system and therefore clearly defined according to the appropriate guidance.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 3 · response
    Published 23 March 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 custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.

    Verbatim wording from the response

    “Whilst Mr Budziszewski was at Bridge Street custody he was not cooperative with the risk assessment process. In any event this should have been reviewed upon his return to Ecclesfield. Custody staff are aware of the importance of the risk assessment and the requirement to regularly review where information is missing and therefore this failure on this occasion is down to officer error and not due to an issue with the training and practices. Appendix A refers to the new risk assessment which has been in force since October 2014.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 2 · response
    Published 23 March 2015

    Open published response
  6. West London

    AI-generated summary

    Lee Sean MACPHERSON · 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

    Lee Sean MACPHERSON was found dead in a safer custody cell at HMP Wormwood Scrubs on 17 October 2012, after being remanded into custody the previous afternoon. Concerns related to incomplete and inconsistently transferred police risk-assessment and escort handover documentation between the police, SERCO and 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 to complete and provide the police risk assessment before custody escort

    Wider context from the report

    “(1) The police risk assessment was not completed until the deceased had already been collected by SERCO and it was a police risk assessment completed in the early hours of the morning that found its way to the prison. ”

    Source location

    Lee Sean MACPHERSON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
Back to top

Data last updated 7 September 2026