Recurring concern

Unreliable officer access to and familiarisation with required operational instructions

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First reported 6 Sep 2015•Latest report 14 Sep 2023

Definition

What this concern includes

Includes failures of arrangements specifically intended to give officers practical access to, time for reviewing, and familiarisation with required operational instructions, including ADAM System/Post Instruction access and systems for ensuring familiarity with local directives and instructions.

Not included

  • Excludes generic officer training, staffing or workload deficiencies where access to or familiarisation with required operational instructions is not the identified unsafe condition.
  • Excludes failures to follow an instruction after the officer had reliable access to and understanding of it.
  • Excludes clinical, prison, aviation or other non-police instruction systems unless the assertion directly concerns officer access to required operational instructions in the same bounded police context.
  • Excludes deficiencies in the substantive content of an instruction where access and familiarisation are not the unsafe condition.
Reports
7

Distinct published reports

Individual concerns
13

A report can raise multiple concerns

Date range
2015–2023

First to latest report issue date

Stated actions
15

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
British Vehicle Rental and Leasing Association1
Care UK1
Chelmsford Prison1
College of Policing1
Corporate Officers of the House of Commons1
Corporate Officers of the House of Lords1
Department for Transport1
Dorset Police1
Family's solicitors1
Hampshire and Isle of Wight Constabulary1
Home Office1
London Ambulance Service NHS Trust1
Maritime and Coastguard Agency1
National Police Chiefs’ Council1

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. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Marcel Maksymilian WOCHNA · 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

    Marcel Maksymilian WOCHNA, aged 15, drowned in the River Itchen on 8 November 2021 after voluntarily entering the water to evade arrest. The inquest found that insufficient immediate action was taken by attending officers to attempt a rescue, and identified inadequate knowledge of the working near water policy. Principal concerns included lack of awareness of Cold Water Shock, rescue procedures, handcuffing risks near water, and the effective dissemination and awareness of the relevant procedure.

    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

    Absence of effective dissemination, access and awareness of the "Working near Water Procedure"

    Wider context from the report

    “4. Absence of effective dissemination, access and awareness of the Hampshire Constabulary "Working near Water Procedure" and the risks, mitigations and the need for necessary dynamic risk assessments set out therein. ”

    Source location

    Marcel Maksymilian WOCHNA · 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

    Disseminate the revised Working Near Water Procedure, provide access to its linked training, and direct frontline staff to complete the updated package.

    Verbatim wording from the response

    “The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the updated E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package.”

    Source location

    Response from Hampshire Constabulary
    Page 2 · response
    Published 18 September 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

    Implement the revised Working Near Water Procedure and require the associated training through the specified delivery arrangements.

    Verbatim wording from the response

    “I believe the implementation of the revised ‘Working Near Water Procedure’, that will mandate the ████████ally and in person, will sufficiently address the concerns set out in the Regulation 28 notice and will equip our officers and staff to maximise the safety of the public when working near water and prevent such tragic circumstances being repeated in the future.”

    Source location

    Response from Hampshire Constabulary
    Page 3 · response
    Published 18 September 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

    Disseminate the revised Working Near Water Procedure, link its e-learning package, and direct frontline officers and staff to complete the updated training.

    Verbatim wording from the response

    “The Constabulary’s revised ‘Working Near Water Procedure’ will be disseminated to all officers and staff. In support of learning and understanding, this will include a link to the adapted E-Learning package associated to this procedure. Frontline operational officers and staff will be directed to complete the updated training package.”

    Source location

    Response from Hampshire and Isle of Wight Constabulary
    Page 2 · response
    Published 18 September 2023

    Open published response
  2. Dorset

    AI-generated summary

    Cherylan CLULOW · 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

    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.

    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 information and steps for sourcing 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
    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

    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
    Page 2 · response
    Published 14 January 2021

    Open published response
  3. Inner North London

    AI-generated summary

    Agnès Blandine Marthe MARCHESSOU · Prevention of Future Deaths report

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

    Report summary

    Agnès Marchessou had experienced fragile mental health for four or five years before her death. After her arrest on 4 July 2020, she was knocked over by a bus on 8 July and taken to hospital. The principal concerns were that police did not pass key information about the incident and her stated reasons for stepping into the road to ambulance or hospital staff, did not promptly make relevant enquiries or record her potential vulnerability, and showed confusion about the required process.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    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
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    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
    Page 3 · response
    Published 30 December 2020

    Open published response
  4. Berkshire

    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.

    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 easy digital access to, and efficient updating and storage of, police procedures and policies

    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
    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 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
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish governance and service-improvement units responsible for developing accessible, role-specific operational guidance.

    Verbatim wording from the response

    “In April 2017 TVP established the Governance & Service Improvement department. Headed by a Chief Superintendent, it consists of 4 separate units, Governance, Service Improvement, Policing Strategy and Change. The Policing Strategy Unit (PSU), Headed by a Detective Superintendent is responsible, amongst other things for the development of simple, up to date and easily accessible operational guidance for front line staff. The operational guidance is developed in layers so staff can access the guidance that is relevant to their particular role. This is built in a ‘Wikipedia’ style so if staff wish to understand more they can click on links to navigate to more detailed explanations of subject matter relevant to the guidance.”

    Source location

    2019-0233-Response-by-Thames-Valley-Police
    Page 4 · response
    Published 13 September 2019

    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

    Update drugs-recovery standard operating procedures into simpler, role-specific operational guidance.

    Verbatim wording from the response

    “The drugs recovery SOP was updated into the new format in July 2019. Prior to this and at the time of the death of Mr Medford this was contained in a Standard Operating Procedure which was long and difficult to both access and understand from an operational officers perspective. The new, simpler guidance is far easier to access and simplified down to the responsibilities of officers role. As an example there is a section headed “observing the detainee” which sets out the responsibilities of those conducting a cell watch.”

    Source location

    2019-0233-Response-by-Thames-Valley-Police
    Page 5 · response
    Published 13 September 2019

    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

    Develop access to simplified operational guidance through officers’ mobile phones.

    Verbatim wording from the response

    “TVP are also developing ways to ensure simple guidance is available on officer’s mobile phones so they can access it in methods that are aligned with modern technology and societal demand.”

    Source location

    2019-0233-Response-by-Thames-Valley-Police
    Page 5 · response
    Published 13 September 2019

    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

    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
    Page 5 · response
    Published 13 September 2019

    Open published response
  5. London Inner (West)

    AI-generated summary

    Kurt Cochran and 5 others · 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 22 March 2017, Khalid Masood drove a vehicle across Westminster Bridge, fatally injuring Kurt Cochran, Leslie Rhodes, Aysha Frade and Andreea Cristea, before fatally stabbing PC Keith Palmer at the Palace of Westminster. The report raised concerns about the protection of public entrances, officers’ access to and understanding of Post Instructions, use of the ADAM System, supervision and training, and wider protective security measures.

    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 clear required intervals for officers to access the ADAM System

    Wider context from the report

    “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process. ”

    Source location

    Kurt Cochran and 5 others · Prevention of Future Deaths report
    Page 5 · 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 provide revised Post Instructions directly to relevant officers

    Wider context from the report

    “MC1: I suggest that the MPS gives consideration to providing revised Post Instructions to relevant groups by direct emails, in hard copy and/or via electronic devices (as well as their being accessible through ADAM) and to providing them in a way that requires the recipient to respond indicating safe receipt. I was concerned that, when Post Instructions were updated, they were apparently not emailed or provided in hard copy to relevant officers directly. The system relied upon officers’ use of the ADAM System, which was sporadic. I am aware from the submissions of the MPS that, since the attack, an update is sent to all relevant officers advising them of a revision of Post Instructions and telling them to view the new version on ADAM. The MPS has provided a copy of an example email, which was sent on 11 October 2018. However, it may be valuable for the MPS to go further than this by supplying revised instructions directly to the officers and in requiring an acknowledgement of safe receipt is sent back by the officers. ”

    Source location

    Kurt Cochran and 5 others · Prevention of Future Deaths report
    Page 5 · 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

    Insufficient time for officers to access the ADAM System and review Post Instructions

    Wider context from the report

    “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions. ”

    Source location

    Kurt Cochran and 5 others · Prevention of Future Deaths report
    Page 4 · 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 brief officers on the rationale for changes to Post Instructions

    Wider context from the report

    “MC10: I suggest that the MPS considers the possibility of the firearms assessor / adviser briefing officers as to the rationale for any changes to their Post Instructions. ”

    Source location

    Kurt Cochran and 5 others · Prevention of Future Deaths report
    Page 10 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of officers to register for and access the ADAM System

    Wider context from the report

    “MC2: I suggest that the MPS considers making it mandatory for officers on the Command to register for ADAM and to access it at specified intervals (perhaps supplemented by an instruction to confirm review of material on the system). I was concerned that a proportion of officers on the Command had not registered for the ADAM System despite it having been in use for six years. Furthermore, I heard evidence that officers were under instructions to access the system “regularly” but no definition of that term could be given. Given that the ADAM System is the repository for the authorised versions of Post Instructions, these were troubling features of the evidence. In short, a proportion of the officers had no means of accessing their instructions and officers generally had no clear guidance on how regularly they should be checking the system. Although the MPS has provided submissions referring to improvements in the ADAM System and improved systems of supervision, these would be relatively simple rules which would be readily enforceable through the disciplinary process. ”

    Source location

    Kurt Cochran and 5 others · Prevention of Future Deaths report
    Page 5 · 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

    Insufficient facilities for officers to access the ADAM System

    Wider context from the report

    “MC3: Given the figures for usage of the ADAM System, it is a matter of concern whether officers have (a) adequate time to access the System regularly and review their Post Instructions and (b) adequate facilities to do so (e.g. ready access to computer terminals). I therefore suggest that the MPS considers the time and facilities available for officers to access the ADAM System and review their instructions. ”

    Source location

    Kurt Cochran and 5 others · Prevention of Future Deaths report
    Page 6 · 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

    Maintain mandatory ADAM registration and regular access, with supervision checks, compliance reporting, and live audit functionality.

    Verbatim wording from the response

    “12. Compliance has substantially improved and the proportion of officers on the PaDP command who have now registered on ADAM is 100%. This is a mandatory element of the induction course into the command which takes place in the first week of joining PaDP. This sets the tone around knowledge requirements when officers arrive at PaDP. For existing officers, separate instructions have been issued around registering and logging into the ADAM system regularly. In addition, there is a separate regime of supervision checks conducted on posts to check that officers are aware of the post instructions and complying with them. These checks are recorded, analysed and produced in a performance report by the IDT. In addition, PaDP has developed a ‘Skills Loss Policy’ to enable officers to be exited from the Command where there is a loss of confidence due to a failure to comply with instructions.”

    Source location

    2018-0304-Response-by-Metropolitan-Police
    Page 4 · response
    Published 20 December 2018

    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

    Email post-instruction changes directly to all PaDP officers, requiring read confirmations and auditing compliance.

    Verbatim wording from the response

    “3. Following the inquests, a great deal of work has been carried out within PaDP in relation to the ADAM system, post instructions and auditing compliance. A temporary system has been introduced whereby officers sign a form before they take over a post so that they have read the post instructions and are aware of their role. This must be completed before an officer can sign out a firearm. Changes to post instructions are now emailed directly to all officers on PaDP, not just supervisors (see para 7 below). Further improvements will be made following the introduction of a digital system currently on trial called AIRBOX (see para 6 below). All Sergeants and Inspectors have been briefed on their operational responsibilities for supervision of officers on posts. Supervisors are set performance targets for post knowledge checks on every shift.”

    Source location

    2018-0304-Response-by-Metropolitan-Police
    Page 2 · response
    Published 20 December 2018

    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 whether officers’ standby time is sufficient for accessing and refreshing post instructions at the scheduled challenge meeting.

    Verbatim wording from the response

    “15. AFOs have periods of standby time between posts of at least one hour, but this can be two hours or more. Officers are aware of their postings three weeks in advance and this time must be used to refresh and improve familiarity with post instructions. All officers are reminded of the need to refresh their knowledge when they come on duty and sign to accept their postings for the day. An agenda item will be raised at the next challenge meeting on 01.03.19 as to whether this time is sufficient. This has also been raised with supervisors on the PaDP command.”

    Source location

    2018-0304-Response-by-Metropolitan-Police
    Page 5 · response
    Published 20 December 2018

    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

    Ensure the PaDP OFC Sergeant explains the rationale for post-instruction changes to AFOs.

    Verbatim wording from the response

    “41. The newly appointed PaDP OFC Sergeant with responsibility for internal tactical advice will ensure that AFOs fully understand not only relevant changes to post instructions but also the rationale behind the changes. This will happen as and when post instructions change.”

    Source location

    2018-0304-Response-by-Metropolitan-Police
    Page 10 · response
    Published 20 December 2018

    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 the ongoing network upgrade to increase officer access to terminals across PaDP sites.

    Verbatim wording from the response

    “17. As stated above, a bespoke IT solution is being developed for the command as a priority. It is anticipated that this will include the use of hand held devices upon which post instructions can be viewed.”

    Source location

    2018-0304-Response-by-Metropolitan-Police
    Page 5 · response
    Published 20 December 2018

    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

    Individual hard copies and mass email distribution of post instructions are restricted by document security and email limitations.

    Verbatim wording from the response

    “8. It is not possible to provide individual hard copies of post instructions to all officers due to the security sensitivity of these documents. There are also restrictions upon emailing such documents to large groups. The MPS has introduced the procedure detailed above as a means of ensuring compliance without compromising security.”

    Source location

    2018-0304-Response-by-Metropolitan-Police
    Page 3 · response
    Published 20 December 2018

    Open published response
  6. South London

    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 required reading and ready reference on restraint techniques and dangers

    Wider context from the report

    “(1) The court was told that officers are not expected to read Standing Operating Procedures and the Officer Safety Manual, and there is little “required reading” or ready reference for police officers regarding restraint techniques and dangers. ”

    Source location

    Olaseni Lewis · 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

    Replace lengthy policing procedures with accessible toolkits, including a live Mental Health Toolkit.

    Verbatim wording from the response

    “At the time of Mr. Lewis’ death in 2010 and at all times subsequently, all MPS SOPs and guidelines on mental health and officer safety have been available to officers on the MPS Intranet. A number of years ago it became accepted that the number and format of SOPs was overly burdensome on officers’ time and it was not realistic to expect them to be familiar with them. To make the guidance easier to access the MPS has reformatted its SOPs into much shorter, and more user-friendly “Toolkits”. The “Toolkits” have been designed to make information easier to locate and comprehend. They contain e- links to related information to provide additional depth and context where required. This change reflects previous learning. The Policing Mental Health SOP has been replaced with a Mental Health Toolkit, which went live in July this year.”

    Source location

    2017-0205-Response-by-Metropolitan-Police
    Page 2 · response
    Published 28 July 2017

    Open published response
  7. Essex

    AI-generated summary

    Warren Martin Sampson · 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

    Warren Martin Sampson had been remanded to HM Prison Chelmsford and was subject to an ACCT when he was found hanging in his cell. Concerns included inconsistent attendance and recording at ACCT reviews, no process for following up non-attendance at first-night healthcare screening, and no system ensuring officers were familiar with local directives and instructions.

    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 system ensuring that all officers are familiar with local directives and instructions

    Wider context from the report

    “(3) The lack of a system for ensuring that all officers are familiar with local directives and instructions ”

    Source location

    Warren Martin Sampson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026