Recurring concern

Unreliable custody handovers

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First reported 6 Jan 2014•Latest report 30 Mar 2026

Definition

What this concern includes

Includes failures of the custody handover process across custody staff and shifts, including absent, ineffective, poorly timed or incomplete handovers that compromise transfer of relevant detainee information.

Not included

  • Excludes failures confined to clinical or social-care handovers without a custody setting or custody handover process.
  • Excludes standalone failures of custody records, risk assessments, observations, staffing or documentation where the report does not link them to the custody handover process.
  • Excludes generic communication deficiencies unrelated to transferring responsibility or information during custody.
Reports
17

Distinct published reports

Individual concerns
18

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
19

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
HM Prison and Probation Service4
South Yorkshire Police3
Medacs Healthcare Limited2
Metropolitan Police Service2
Practice Plus Group2
Bedford Prison1
Betsi Cadwaladr University LHB1
Birmingham Prison1
Cookham Wood Prison1
Crown Prosecution Service1
Department of Health and Social Care1
GeoAmey PECS Limited1
Greater Manchester Combined Authority1
Greater Manchester Mental Health NHS Foundation Trust1

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. 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 communicate identified mental health concerns to custody staff

    Wider context from the report

    “7. Both arresting officers formed the view that ████████ was suffering mental health or substance abuse problems, and both included these two factors in their statements, but the custody sergeant gave evidence that no mental health concerns were brought to his attention. ”

    Source location

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

    Open source report

  2. West London

    AI-generated summary

    Olawale ADELUSI · 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

    Olawale Adelusi was arrested on 28 October 2014 and, after attempting suicide by hanging at court, was remanded to HMP Wormwood Scrubs, where he was found hanging in his cell on the morning of 3 November. The principal concern was the absence of an effective system for transmitting information relevant to the risk of self-harm and mental health, including information recorded during his police custody and hospital supervision. The inquest jury recorded the failure to transfer information and documentation at each stage as a contributory factor.

    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 an effective system for transmitting information relevant to detained persons’ self-harm risk or mental health assessment

    Wider context from the report

    “The absence of an effective system to ensure appropriate transmission of all information relevant to assessment of the (i) risk of self-harm or (ii) mental health, of detained persons BASIS OF CONCERN : – Whilst in police custody Mr Adelusi had been taken to hospital where he remained under police guard. Police Officers kept a Hospital Guard Supervision Log covering a 6.5 hour period and it recorded that Mr Adelusi had: on several occasions deliberately thrown himself from bed to floor in such a way as to cause concern for his safety; been observed crying on several occasions; been observed banging his head on the floor; spoken of a plot to kill him and of his son having been killed by police; and tried to bite the clinical drip pipe. On return to the police station, Mr Adelusi was kept under constant supervision and a Constant Supervision Log was maintained by officers over a period of 23 hours in which they recorded that he had been observed: "pushing his thumbs down on to his neck" until he had to be told to desist; urinating in the corner of his cell; whispering to the Forensic Medical Examiner "they've killed him"; again crying and saying "you've killed him"; trying to strangle himself with a vest; kneeling with his head against the floor, crying; and accusing officers of killing his children and asking to see their bodies. Neither the logs, nor the information recorded in them, was included in Mr Adelusi's Personal Escort Record; nor was that information otherwise transmitted in writing to those responsible for his detention after removal from the police station. Whilst there was evidence of a verbal handover to Escort Personnel, at which some of this information may have been mentioned, no record was made of that conversation. ”

    Source location

    Olawale ADELUSI · 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

    Include the Prisoner Escort Record process in the next custody staff training cycle.

    Verbatim wording from the response

    “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

    Source location

    Olawale-ADELUSIR-1
    Page 4 · response
    Published 22 July 2016

    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 initial-course training for new custody staff on the Prisoner Escort Record process.

    Verbatim wording from the response

    “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

    Source location

    Olawale-ADELUSIR-1
    Page 4 · response
    Published 22 July 2016

    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 Prisoner Escort Record guidance provided through the Custody Toolkit.

    Verbatim wording from the response

    “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

    Source location

    Olawale-ADELUSIR-1
    Page 4 · response
    Published 22 July 2016

    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 a quality-assurance monitoring system to assess the quality of Prisoner Escort Record completion.

    Verbatim wording from the response

    “For the time being, therefore, and for some time to come, the MPS must continue to use the current form. As an interim measure we have taken steps to refresh the awareness of our custody staff of the importance of completing the existing form correctly. Specifically, in the light of this review MPS Met Detention are implementing the following measures:”

    Source location

    Olawale-ADELUSIR-1
    Page 4 · response
    Published 22 July 2016

    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

    NOMS owns the PER design and protocols, while national solutions require multi-agency action driven by NOMS and supported by other stakeholders.

    Verbatim wording from the response

    “The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS.”

    Source location

    Olawale-ADELUSIR-1
    Page 2 · response
    Published 22 July 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The MPS cannot unilaterally change the PER system because changes require agreement from NOMS and all participating agencies.

    Verbatim wording from the response

    “The design of the form and protocols for its use are the responsibility of NOMS, though the current form and any future versions will be agreed in discussion and agreement with all the stakeholders who use the form. The current PER was first issued in 2009 and its use adopted across all agencies during 2010. The PER is currently used by the police, NOMS, Secure Hospital Estate, the Home Office (for immigration detainees) and the escort contractors. The Metropolitan Police are therefore merely one of a number of users of the system, and whilst we can make suggestions and influence the future development of the system from this position, such changes would need to be made in agreement with all the other participating agencies, and with NOMS.”

    Source location

    Olawale-ADELUSIR-1
    Page 2 · response
    Published 22 July 2016

    Open published response

  3. North Wales (East and Central)

    AI-generated summary

    Andrew Selwyn Roberts · 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

    Andrew Selwyn Roberts was arrested on 24 December 2011, after being tasered and having taken an overdose, and was taken to hospital before being assessed as fit to return to custody. The transfer of care form inaccurately stated that he had been assessed by psychiatric liaison, although he had not been seen by that team. The substantive concerns were that the form was completed by a nurse rather than the examining doctor, contained inaccurate information, and was not completed and provided to police at the time of examination.

    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 provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse

    Wider context from the report

    “2. That the Transfer of Care Form was not completed at the time of examination and provided to the Police Officers escorting the detained person to hospital so that it could be returned with them to custody and made immediately available to the custody nurse. ”

    Source location

    Andrew Selwyn Roberts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Kesia Lena Mary Leatherbarrow · 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

    Kesia Lena Mary Leatherbarrow, aged 17, died on 3 December 2013 after tying a ligature around her neck. The report describes missed opportunities among multiple agencies to obtain and share information, assess risks, and provide appropriate support, including concerns about her care and information handling while in police 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

    Custody handovers dependent on officers’ and staff’s unpaid free time

    Wider context from the report

    “The system at present relies on officers and staff attending work early and sometimes staying late after a 12 hour shift to provide a handover. Whilst it is clear there would need to be some overlap in the times people are on duty, the Court heard evidence as to the quality of the handovers which is clearly impacted by the fact that this crucial part of the information sharing process relies entirely on the free-time of officers and staff. ”

    Source location

    Kesia Lena Mary Leatherbarrow · Prevention of Future Deaths report
    Page 7 · 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 handover causing unsafe changes to detainee observations

    Wider context from the report

    “(26) The handover from the night custody sergeant to the morning custody sergeant was incomplete. Whilst CCTV makes plain that Mr Budziszewski was described as an alcoholic, there was no reference to the retching episode or the change in observations. In consequence of this latter point Mr Budziszewski was inadvertently changed back from 30 minute checks to 60 minutes without any consideration of needs. ”

    Source location

    Neil Budziszewski · 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

    Incomplete handover of detainee health risks and observation requirements

    Wider context from the report

    “(16) The handover from the afternoon custody sergeant to night custody sergeant did not include information about Mr Budziszewski being prescribed Methadone, that he was an alcoholic, or that he was on 30 minute checks. This was accepted not to be a full and effective handover. ”

    Source location

    Neil Budziszewski · 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

    Document and standardise custody handover requirements, including transfer of risk-assessment information.

    Verbatim wording from the response

    “The process for handovers is now documented and is consistent across the force. The process is that the sergeant handing over will summarise to the incoming sergeant personal information about the detainee, details of the offence and the stage of the investigation and any specific risk factors. The focus of the handover is to be around the risk assessment which has been completed. Appendix C shows a completed copy of the handover Sergeants are expected to complete. As this is a live copy, third party data has been redacted out to ensure compliance with the Data Protection Act.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 5 · 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

    Regularly train current and new custody staff on the standardised handover process.

    Verbatim wording from the response

    “Unfortunately this was an example of extremely poor recording keeping. That cannot be defended however it is certainly below the expectations of South Yorkshire Police. The custody staff involved have all been spoken to following the inquest and advised of this issue and told of the expectations upon them. It is also anticipated that the new handover process should ensure this does not happen going forward and this process will be regularly trained to custody staff, current and new.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 8 · response
    Published 23 March 2015

    Open published response

  6. Manchester West

    AI-generated summary

    Jake Reginald Hardy · 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

    Jake Reginald Hardy, a 17-year-old detained at HM YOI Hindley, died on 20 January 2012 after being found partially suspended by a ligature in his cell. The report describes failures to identify, record and respond to his vulnerabilities, self-harm risk and reports of verbal bullying, including failures in safeguarding, ACCT care planning, supervision and overnight risk assessment. Concerns also included ligature points in cells, inadequate personal officer support, staff training and communication systems, and limited access to family telephone support.

    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 reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover

    Wider context from the report

    “6. The shift patterns of Senior Officers working on the wings within HM YOI Hindley are such that they do not always overlap and handover is often by means of written entries in a “handover book”. The handover book I saw contained short notes addressing random matters and there was apparently no routine recording of a more comprehensive review of the shift. There is no system in place to ensure that important information and outstanding tasks are sufficiently recorded by one Senior Officer at the end of his shift and then read by the next Senior Officer at the start of his shift. It was clear from the evidence that it is the Senior Officer’s responsibility to have an overview of what is happening on the wing and matters of relevance to the safeguarding of detainees housed there. Therefore, the passing of key information and outstanding tasks between Senior Officers on a wing is of real importance to the safety of detainees. This concern may be of relevance to other Young Offender Institutes also. ”

    Source location

    Jake Reginald Hardy · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · 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

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    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

    Ineffective or absent handovers between custody staff

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · 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

    Standardise sergeant handovers around accurate Custody Summary Screens and communication of key detainee risk information.

    Verbatim wording from the response

    “We have conducted a review of handovers between sergeants. As a result we have made it clear to sergeants that the handover need not be a comprehensive review of each detainee. Rather, they should have completed the Custody Summary Screen so that all the relevant detail is available on the ICIS system and the handover should contain key risk issues, for example medical conditions, medication required and so forth.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 3 · response
    Published 6 January 2014

    Open published response
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Data last updated 7 September 2026