Recurring concern

Unreliable recording in police custody records

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First reported 6 Jan 2014•Latest report 23 Oct 2024

Definition

What this concern includes

Includes failures of the police custody-recording process that result in inaccurate, incomplete, omitted or misleading records of force, healthcare referrals, visits, observations, risks or other safety-relevant custody information.

Not included

  • Excludes failures in the underlying custody care, observation, referral or force-management process when the custody record itself is not deficient.
  • Excludes generic clinical or care-record deficiencies outside police custody.
  • Excludes failures limited to custody handover or information transfer where the custody records are accurate and the problem is only communication between staff.
  • Excludes administrative custody records that have no material safety relevance.
Reports
13

Distinct published reports

Individual concerns
27

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
22

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.

Greater Manchester Police4
National Police Chiefs’ Council3
GeoAmey PECS Limited2
Medacs Healthcare Limited2
Metropolitan Police Service2
NHS England2
South Yorkshire Police2
Association of Ambulance Chief Executives1
Central and North West London NHS Foundation Trust1
College of Policing1
Crown Prosecution Service1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Department of Health and Social Care1
Dorset Police1
Dorset & Wiltshire Fire and Rescue Service1

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. Sunderland

    AI-generated summary

    John Paul Hurst · 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

    John Paul Hurst, who had a history of paranoid schizophrenia and previous suicide attempts, was released from custody on 13 September 2021 after concerns had been raised about his mental health and risk of suicide. He was found near train tracks on 15 September 2021 and died from haemorrhage associated with severe injury to his right leg, consistent with impact with a train. The principal concern was that the electronic custody record inadequately documented the mental-health and suicide-risk concerns, and lacked detailed analysis and reasoning for the CJLD assessment conclusion.

    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 record detailed information about detained persons’ mental health concerns

    Wider context from the report

    “At the Inquest I heard evidence that, following John’s arrest, concerns were expressed by police officers involved in the investigation as to his mental health, and by John’s sister as to his risk of ending his own life. These concerns were repeated by John’s sister to the Criminal Justice Liaison and Diversion Service (CJLD) prior to his assessment. The evidence was that when completing the release risk assessment, the custody sergeant had been greatly assisted by the information recorded on the electronic custody record regarding the concerns that led to the mental health assessment and the assessment itself, in addition to the custody sergeant’s own observations. The evidence highlighted that the electronic custody record contained limited information about the concerns of police officers and John’s sister, and there was a distinct lack of detail about the assessment itself and very little analysis of the concerns and reasoning for the CJLD conclusion. I am concerned that the information on the electronic custody record was inadequate and lacked detail regarding the concerns for the detained person’s mental health, as identified by police officers and family, including the risk of suicide, the content of notes found and the detained persons history of suicidal ideation and previous engagement with mental health services. In addition, I am concerned that the record also lacked a detailed analysis of those concerns by CJLD and comprehensive reasoning for the assessment conclusion. ”

    Source location

    John Paul Hurst · 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

    Provide custody staff with instruction and learning on recording detainees’ mental-health concerns through the Custody Newsletter, Custody Compendium and direct reminders to Custody Sergeants.

    Verbatim wording from the response

    “I agree that it is important that custody officers record all relevant information and concerns expressed in relation to the mental health of a detainee. This is something which all custody officers should be aware of. In order to ensure that custody staff are aware of their obligations in this respect, following receipt of your report appropriate instruction and learning from this Inquest has been provided to custody staff via:”

    Source location

    Response from Northumbria Police
    Page 1 · response
    Published 24 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.

    Verbatim wording from the response

    “The Trust has carried out a thorough review of the guidance provided to staff in relation to entering information onto the electronic custody record and the following changes have been embedded:”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS
    Page 2 · response
    Published 24 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.

    Verbatim wording from the response

    “The updated Local Operating Procedure was circulated to staff on 12 November 2024 via email, please see "Exhibit A". Team training also took place on the 13 November 2024 to discuss the updated guidance. During”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS
    Page 2 · response
    Published 24 October 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.

    Verbatim wording from the response

    “In addition, CJLD Clinical Leads have been given express permission by the Northumbria Police (Superintendent responsible for Custody), to audit Trust staff entries into the electronic custody record provided the reason for accessing the record is documented. Clinical Audit of CJLD screening documentation and will be carried out by CJLD Clinical Leads monthly for every staff member. Three random samples are selected for each staff member each month. Audit includes records made on both ECR and RiO. Audit outcomes are and will be discussed in monthly Clinical Supervision.”

    Source location

    Response from Cumbria, Northumberland, Tyne and Wear NHS
    Page 3 · response
    Published 24 October 2024

    Open published response
  2. West Sussex, Brighton and Hove

    AI-generated summary

    Miles Ethan Hurley · 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

    Miles Ethan Hurley died at 5.58am on 10 July 2022 after intentionally driving his father’s car towards an HGV lorry while experiencing a psychotic episode. The report identified concerns about inadequate communication and documentation between police officers, the Liaison Diversion Service and mental health services, including the handling of family information and mental health assessments while he was intoxicated. It also identified gaps in guidance, availability and procedures for mental health assessment, appropriate adult support and ongoing care in custody.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of formal police documentation of family concerns about mental health deterioration

    Wider context from the report

    “2. Lack of relevant Documentation by the Police Throughout Mr Hurley’s time in custody on the 9th July 2022, his parents spoke to multiple police officers and allied staff on the phone and on attending the custody suite to inform them of their concerns over their son’s sudden deterioration in his mental health on a background of longstanding extreme social anxiety. Whilst this was generally known by the officers within the custody suite, there was no formal documentation, either individually or collectively of these concerns to inform and assist police officers in their decision making. ”

    Source location

    Miles Ethan Hurley · Prevention of Future Deaths report
    Page 5 · 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

    Add information received from detainees’ families to the custody care plan so concerns are formally recorded and addressed.

    Verbatim wording from the response

    “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).”

    Source location

    Response from Sussex Police
    Page 3 · response
    Published 29 July 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Complete and regularly review detainee risk assessments and care plans, recording changing physical or mental health information and responding to identified risks.

    Verbatim wording from the response

    “A Custody Officer (Sergeant or Detention Officer) will complete an Initial Risk Assessment of the detainee on arrival and a Pre-Release Risk Assessment on their release from Custody. In every case a Care Plan is created to mitigate identified risk(s).”

    Source location

    Response from Sussex Police
    Page 3 · response
    Published 29 July 2024

    Open published response
  3. South Yorkshire (Western)

    AI-generated summary

    Matthew Terrill · Prevention of Future Deaths report

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

    Report summary

    Matthew Terrill was taken into police custody on 22 April 2020 while intoxicated by multiple drugs and exhibiting behaviour associated with drug intoxication and possibly acute mental health symptoms. He was placed on level 4 constant observations, during which officers with limited experience and no briefing observed him until he was found not breathing. The substantive concerns included inadequate police training on drug intoxication, mental health symptoms, positional asphyxia, constant observations and custody handovers, as well as weaknesses in documentation and supervision processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of audit trail for signed constant observation forms and sergeant briefings

    Wider context from the report

    “6. Lack of safety net for custody suit documentation, specifically the constant supervision forms. I am told that whilst there has been a welcomed change to the format of the constant observation forms, there is no safety net for ensuring that these forms are handed over in a timely manner or by the custody sergeant. I am also told that there is no audit trail in place for checking that these forms are being signed by police or custody officers to ensure that the envisaged sergeant briefing is being given. I am concerned that there is a risk of future death to detained persons on level 4 constant supervision in circumstances where the sitting officers may not be experienced in the task, have not been trained, and are not consistently being briefed by the custody officers. ”

    Source location

    Matthew Terrill · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct compliance dip sampling, including CCTV checks, to verify constant-observation briefings and supervisory checks.

    Verbatim wording from the response

    “Training/ CPD will be given to all Custody Sergeants following this review setting out clear standards and expectations around their role and responsibilities of this document. Dip samples will be carried out by the Custody Inspectors to ensure compliance, this will include reviewing of CCTV to ensure that this document is briefed, relevant checks by the Sergeant are carried out for anyone under constant observations.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 7 · response
    Published 4 April 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Consult the Performance and Governance team about activating body-worn video during constant observations.

    Verbatim wording from the response

    “The Custody lead for South Yorkshire Police is to have further consultation with the Performance and Governance team to look at whether BWV should be activated when observing a prisoner, this could then capture the briefing, roles and responsibilities, action of the officers and any behaviour of the detainee.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 7 · response
    Published 4 April 2024

    Open published response
  4. 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 identification, collation and recording of factors increasing detainee risk on the Niche system

    Wider context from the report

    “i. There is not sufficient clarity in the identifying, collating and recording of factors which may increase a person’s risk on the Niche system that Dorset Police, and other forces nationally, use and as a result information could be missed which is vital to a person’s risk assessment and their risk to themselves or others. ”

    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

    Seek customer-force views on changes needed to reduce recurrence risk.

    Verbatim wording from the response

    “Action has already been taken which includes:”

    Source location

    Response from NicheRMS
    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

    Work with the Minerva Management Board to assess the reported risk-identification and recording issues.

    Verbatim wording from the response

    “However, given the significant nature of the issue you have raised, I would expect forces, as a minimum, to have received some more permanent solution to the concern you have outlined when they next upgrade. And, given that most Niche forces upgrade on an annual basis, this will have an immediate impact on the risks presented by the lack of clarity in identifying, collating and recording risk factors in NicheRMS365. I can reassure you that, together with colleagues from MMB, we are actively looking at the issues you have raised.”

    Source location

    Response from NicheRMS
    Page 3 · 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 Custody Record dropdown menu to capture factors increasing detainee risk.

    Verbatim wording from the response

    “We have updated the Niche system in a way that we believe addresses this concern. A dropdown menu is now included in the Custody Record for every detainee for the purposes of capturing such information.”

    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

    Amend Niche occurrence-log Section 2 to prompt consideration of detainee risk and vulnerability.

    Verbatim wording from the response

    “In short, we are in the process of implementing changes to Niche, locally, which will see Section 2 of Occurrence Logs on Niche amended, to prompt the Custody personnel to consider risk and vulnerability regarding the detainee in question.”

    Source location

    Response from Dorset Police
    Page 4 · 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

    Niche Technology cannot require customers to install patches or activate specific RMS changes.

    Verbatim wording from the response

    “I would not wish to pre-empt recommendations of the Minerva Criminal Justice Working Group on this matter, so the method of change is not presently clear. Further, I have not seen the response from the College of Policing who may issue additional guidance and changes to the risk assessment process that will need to be factored into any change we make to the RMS. I note also, that Niche Technology can not insist that customers install patches or turn on any specific change in their upgrades.”

    Source location

    Response from NicheRMS
    Page 3 · 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
  5. Manchester South

    AI-generated summary

    ANTHONY JAMES FITZPATRICK · 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

    Anthony James Fitzpatrick had a long history of mental health problems and attended local A&E departments on three occasions in the year before his death, with two attendances followed by custody. The report identified inconsistent and inaccurate assessment of risk by healthcare professionals, with unclear risk grades recorded in the electronic custody record and no plan to address the problem despite it being known.

    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 ensure that recorded risk grades have a clear shared meaning

    Wider context from the report

    “(1) During the course of the evidence, it became apparent that the HCPs were not using objective and/or consistent criteria to assess the risk of ████████, meaning that (a) the grade of risk assigned to AF was inconsistent and/or inaccurate and (b) no one else knew what was meant by the grade of risk recorded in the electronic custody record. (2) Further, none of the HPCs who gave evidence used the criteria described in the online training materials. (3) Despite being aware of this problem, there was no plan in place to address it. ”

    Source location

    ANTHONY JAMES FITZPATRICK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Lincolnshire

    AI-generated summary

    Carlington Maurice Spencer · 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

    Carlington Maurice Spencer, a detainee at Morton Hall IRC, suffered a right middle cerebral artery infarction after being found unwell and was later confirmed deceased on 3 October 2017. The report identifies concerns about confirmation bias relating to presumed drug use, inadequate monitoring and record keeping, poor communication and escalation between discipline and healthcare staff, failures to recognise stroke symptoms, and delays in emergency treatment.

    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

    Inaccurate, irregular and unavailable records of incapacitated detainees

    Wider context from the report

    “1. The case demonstrated the failures of existing systems, management and working practices within the Discipline staff employed by Morton Hall IRC namely: a. The existence of "confirmation bias" or "confirmatory bias" when dealing with detainees with a known history of recreational use of drugs in such a way that when a detainee presents in a manner that is interpreted as being presumed and/or assumed to be under the influence of drugs, this presumption and/or assumption is not challenged or tested or verified (as an example, by meaningful searches of the detainee or his room; review of CCTV evidence or escalation for advice from healthcare personnel); b. Concerns of co-detainees are not appreciated or noted or actively sought; c. Record keeping and purported observations of detainees who are incapacitated by reason of presumed self-induced intoxication are inaccurate, irregular and unavailable for inspection by health care personnel; d. Discipline staff have no meaningful training on the categories of self-induced intoxication and in particular "new psychoactive substances" such as the synthetic cannabinoid known as "Spice"; e. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with a presumed "Spice" related incident; f. There is no adequate communication or working protocols as between Discipline staff and healthcare staff for clear escalation pathways when dealing with an incident that may have commenced as a drug related incident but develops into a potential medical emergency; g. Access, review, storage and retrieval of CCTV footage is inadequate and unsatisfactory; ”

    Source location

    Carlington Maurice Spencer · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
  7. Manchester South

    AI-generated summary

    Adam Harris · 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

    Adam Harris died at Tameside General Hospital on 20 April 2018 from alcohol and cocaine toxicity after collapsing at Ashton Police Station following his arrest and detention. Concerns included the absence of documented triage or risk assessment while prisoners waited in the van dock, lack of searches before transport, unclear handover arrangements, delayed creation of the custody record, and inconsistent evidence about his position in the cell while confused and suspected to be intoxicated.

    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

    Delays in opening and entering information in custody records

    Wider context from the report

    “4. The Custody Sergeant did not open a custody record immediately on Adam Harris’s arrival in the custody office. He used a piece of paper to record the details that were given to him. He did not input details into the custody record until after Adam Harris had been placed in a cell. He indicated that the custody Sergeant course encouraged the use of paper and he had developed his practice from the guidance on the course. It was unclear how the paper was stored and how it supported the requirement to follow the process generated through using the custody system; ”

    Source location

    Adam Harris · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  8. Inner North London

    AI-generated summary

    Jeroen ENSINK · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to accurately record suspected cannabis use

    Wider context from the report

    “9. Both arresting officers thought there was a possibility that ████████ was under the influence of cannabis. The custody sergeant recorded this as heavy cannabis use, he said because in his experience people who use cannabis use it heavily. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 3 · 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 maintain consistent and accurate recording of alleged weapon threats

    Wider context from the report

    “4. The custody sergeant who booked ████████ into custody recorded that ████████ had threatened police officers with a knife, though there was no mention of this on the CRIS (crime record information system) report or in the officers’ statements, and both officers gave evidence at inquest that ████████ had not had a bladed article in his possession when they arrested him. This was later found on the windowsill through which he had climbed into the property. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 3 · 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 record force used during arrest

    Wider context from the report

    “6. The arresting officers described in evidence a violent struggle with ████████ when they arrested him. He had tried to grab the Taser belonging to one of the officers. Yet the custody sergeant recorded that no force had been used. And this was despite the fact he said that he was under the impression that ████████ had wielded a knife against the officers. He said in evidence this was because the force had been used outside the police station. ”

    Source location

    Jeroen ENSINK · Prevention of Future Deaths report
    Page 3 · 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 accurately record detainee injuries

    Wider context from the report

    “5. The custody sergeant noted that ████████ had a bruised, bleeding and swollen lip, yet to the custody record question regarding any injuries, he recorded no. ”

    Source location

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

    Open source report
  9. Central Hampshire

    AI-generated summary

    Michael Folley · 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

    Michael Folley was remanded to HMP Winchester on 15 September 2017 and was found the following day suspended from a ligature made from torn bed sheets after barricading his cell door with mirrors and furniture. He was taken to hospital and died on 18 September 2017 after intensive care treatment. The principal concerns included the transfer and use of information about self-harm risk between police, court and prison; staff training; cell safety and maintenance; systems for checking barricaded cell doors; and the effectiveness of prison radios in relaying emergency calls.

    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 record checks of PER completion and quality

    Wider context from the report

    “e) The responsibility for the completion and quality of the PER rests with the releasing Custody Sergeant. When checking the detention log in the custody record in this case, there was no specific entry. This may not necessarily mean it was not checked by the custody sergeant but if it was then that action should be recorded. f) It is the custody sergeant’s responsibility to ensure the safe transportation of a PER and associated documents by placing them in an envelope or other secure means that all documentation is safely handed over to the court custody officers. ”

    Source location

    Michael Folley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.

    Verbatim wording from the response

    “Force Custody publishes a quarterly newsletter to all custody officers and detention officers. The next publication is due in September 2019 and will reinforce the issues addressed in this Regulation 28 Notice.”

    Source location

    2019-0230-Response-by-Hampshire-Constabulary
    Page 2 · response
    Published 18 July 2019

    Open published response
  10. 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

    Custody-record systems that readily permit errors

    Wider context from the report

    “2. An erroneous entry was inserted into Mr Jasiunas’ record by an FME. The entry had the effect of providing false assurance to custody staff. The evidence revealed that errors on the custody records are commonplace and that the current design of the system renders errors easily made. Suggestions for improvements of the system included photographs of the detainee on the computer system; more prominent indication of the detainees surname at the top of the medical form; pop-up prompts to remind the healthcare practitioner to ensure that they have identified the correct detainee before prescribing medication; changes to prevent medication from being entered onto a person’s custody record in the absence of an accompanying medical form being completed at the same time. ”

    Source location

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

    Open source report
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Data last updated 7 September 2026