Recurring concern

Unreliable custody handovers

Pin Get email alerts Request correction

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

    Rickie Wai Kee POON · 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

    Rickie Poon, a dismissed police officer detained under the Mental Health Act and later remanded in custody at HMP Pentonville, was found hanging in his cell one month after arriving at the prison. The jury found failures in the prison’s ACCT process contributed to his death, including inadequate management, accountability, training, implementation of actions and the early closure of the ACCT; concerns were also raised about inappropriate CPR after he had died.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to complete handovers between ACCT staff

    Wider context from the report

    “The jury found that the following failures at HMP Pentonville in the ACCT (assessment care in custody and teamwork) process contributed to Mr Poon’s death: • the ACCT process was not managed and implemented properly, e.g. supervising officers did not consistently acquaint themselves with case notes or history when completing reviews; record keeping was inadequate; agreed actions were not consistently implemented; and ACCT reviews lacked structure and consistency; • accountability was insufficient, e.g. there was no follow up when actions were missed in the ACCT document, sign offs were completed inaccurately, hand overs were not completed between staff, and an important email was not read or followed up on; • there were gaps in training and knowledge, e.g. ACCT training had expired and prison staff overly relied on Rickie’s presentation; • the ACCT was closed too soon. The jury also found that the level of ACCT observations was reduced inappropriately, but they were unclear as to whether this impacted on the outcome. ”

    Source location

    Rickie Wai Kee POON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.

    Verbatim wording from the response

    “We do not propose to respond to the points raised above in respect of HMPPS and HMP Pentonville as these matters are for separate organisation.”

    Source location

    Response from Practice Plus Group
    Page 3 · response
    Published 10 April 2026

    Open published response

  2. South Yorkshire (Western)

    AI-generated summary

    Roger Gary Leadbeater · 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

    Roger Gary Leadbeater died on 9 August 2023 from multiple stab wounds inflicted by a patient detained under the Mental Health Act who had absconded from escorted leave. The report identified concerns about inadequate and poorly recorded handovers between police forces and the mental health trust, which meant significant risk information was not clearly communicated and may have affected decisions to grant leave. It also noted that, as of January 2026, relevant policies and auditing arrangements had not been updated to support the use of new handover forms.

    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 clearly record police handovers

    Wider context from the report

    “During the inquest evidence was given by both South Yorkshire Police and Greater Manchester Police that hand overs between police forces, and between Greater Manchester Police and the Greater Manchester Mental Health NHS Foundation Trust were inadequate and not clearly recorded. This resulted in the Greater Manchester Mental Health NHS Foundation Trust being unaware of, or unclear about, significant risk factors such as the patient assaulting others, making threats to harm others, using drugs and carrying weapons during her periods of absence. This impacted on their subsequent decision to grant the patient leave, including the granting of leave for the final time, two days before Roger died. The inquest heard that handover forms were being developed by both forces and policy changes were planned to support the new form, but this process had not been completed. The evidence provided to the Court on 7 January 2026 was that, as in August 2023, the content and quality of hand overs still relied on individual officers acting without guidance or documentation. On 22 January 2026 the Court was told both police forces now have a hand over form, but both forces have not updated the relevant policies to support its implementation or audit its use. I am concerned that without a robust handover process in place, key information about those detained under the Mental Health Act and being transported by police will not be appropriately communicated. This is turn may affect risk assessments and decisions around patients being granted leave. ”

    Source location

    Roger Gary Leadbeater · 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

    Amend Form 1157 and the supporting policy to mandate structured recording and handover of risk information across specified mental-health conveyances.

    Verbatim wording from the response

    “To address the issues that presented in Mr Leadbeater’s case, GMP has amended Form 1157 and moreover extended the circumstances in which the form is mandated for completion. The form must now be completed whenever officers take or convey (or assist in conveying) a person to hospital under any of the following circumstances:”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 2 · response
    Published 29 January 2026

    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, test and release the Form 1157 mobile app with the revised structure and mandatory risk-information fields.

    Verbatim wording from the response

    “To ensure the amended Form 1157 is fully embedded into frontline practice, GMP is also updating the digital version of the form used on officers’ mobile devices. An initial meeting to scope the required changes to the 1157 mobile app took place on 23rd February 2026, during which the technical and operational requirements were agreed. The final sign off for the project is due to take place on 16th March 2026 after which development work will begin. It is estimated that it will take 3 months for the completion of testing and for full release of the app to take place.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 4 · response
    Published 29 January 2026

    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

    Run a monthly comparison of hospital-originating missing-person episodes against Form 1157 submissions to identify missing documentation.

    Verbatim wording from the response

    “The Missing Person Safeguarding Unit within the Public Protection Division will run a monthly report identifying all Missing Person episodes originating from hospitals. This will be shared with the Prevention Hub to compare against their 1157 submissions via the updated app, ensuring that the required documentation has been completed for every relevant incident.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 5 · response
    Published 29 January 2026

    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

    Require PRISM Care Plan triage staff to verify Form 1157 completion and attachment before closing relevant Care Plans.

    Verbatim wording from the response

    “In addition, completion of the 1157 has now been incorporated into the new PRISM app used by District Safeguarding Teams (MASH). Officers and staff triaging Care Plans must confirm that the Form 1157 has been completed and attached before a Care Plan can be closed. This creates a clear check-and-balance within the system and prevents closure where the correct safeguarding paperwork has not been provided.”

    Source location

    2026-0041 - Response from Greater Manchester Police
    Page 5 · response
    Published 29 January 2026

    Open published response

  3. Avon

    AI-generated summary

    Ms. Amy Jo Cross · 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

    Ms. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.

    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 for passing important healthcare information between criminal justice healthcare providers during conveyance

    Wider context from the report

    “(1) There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare in the criminal justice system at the time a person is conveyed between the police, the court and the prison. ”

    Source location

    Ms. Amy Jo Cross · 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

    Continue discussions with PECS to commence pilots enabling Liaison and Diversion services to access and update the Digital Person Escort Record.

    Verbatim wording from the response

    “NHS England does commission Liaison & Diversion services, which also operate with police custody suites, addressing mental health and wider vulnerabilities. There is no indication that a referral was made in this case to Liaison & Diversion services at either Torquay or Exeter police custody suites. Liaison & Diversion services do not currently have access to enter information directly onto the DPER, but with an individual’s consent, they will share relevant health information with the police and the police will be responsible for updating the DPER. NHS England is in discussion with PECS to commence pilot schemes in London and West Yorkshire, whereby PECS will issue licences to Liaison & Diversion Services, to enable them to directly access the DPER and enter health information. The pilots are expected to commence in 2026 at the following sites:”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 October 2025

    Open published response

  4. Bedfordshire and Luton

    AI-generated summary

    Steven HART · 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

    Steven Hart was remanded to HMP Bedford in November 2022 and, after episodes of self-harm and deterioration in his mental health, was found unresponsive in his cell on 25 March 2023 after using a ligature attached to a faulty observation panel. He was taken to hospital and died on 29 March 2023 from asphyxiation due to hanging. The principal concerns were failures in cell safety, communication and handovers, mental health assessment, and the carrying out and escalation of observations after self-harm incidents.

    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 relevant risk information through handovers and records

    Wider context from the report

    “1. Failure to Adequately Monitor and Audit Cells for Ligature Points Mr Hart was placed in a “safer cell” designed to have no ligature points. However, the observation panel ████████ was broken, ████████ which he was able to thread a ligature and hang himself. Staff and witnesses confirmed that the damage to the cell door was known, and that maintenance was generally responsive, but the cell was not taken out of use despite the increased risk. The prison’s own post-inquest review acknowledged that the design of the observation panels allowed prisoners to open them from inside, creating an opportunity for self-harm. Interim and permanent solutions were only implemented after the Inquest had commenced nearly two and a half years after Steven's death indicating a likely failure to tackle safety concerns promptly or appropriately. 2. Failure to Effectively Communicate Risk and Incidents There was a general failure to distribute and communicate relevant observations and concerns regarding Mr Hart’s mental state. Staff often did not have time to receive handovers or read current and previous ACCT (Assessment, Care in Custody and Teamwork) documents during their shift. After a serious self-harm incident with Steven involving ████████ the officer involved failed to report the incident to OSCAR 1 (the officer in charge), as required by protocol. He simply removed the ████████ and did not conduct any further assessment or review of Steven. This failure prevented a multi-disciplinary review and possible escalation of risk management. The night shift handover on 25 March 2023 was insufficient, with lack of vital information provided to the receiving officer, leading to inadequate understanding of Mr Hart’s risk. 3. Failure to Carry Out Appropriate Observations Observations of Mr Hart were reduced from constant supervision to four irregular checks per hour, despite ongoing risk factors and recent self-harm attempts. CCTV evidence suggested that required observations were not always carried out to the proper standard, and some checks may not have been performed at all. The officer insisted they were carried out, although CCTV evidence strongly suggested that was improbable. The jury found that the failure to call OSCAR 1 after the telephone cord incident directly impacted Mr Hart, as it possibly prevented a further ACCT review and escalation of observations or removal of ligature materials. The death of Steven Hart was contributed to by systemic failings in cell safety, communication, and observation practices. There were, paradoxically, along-side poor practice and care, examples of exceptionally good practice by a group of officers of which several have left the prison service. There was generally a failure to implement robust systems for cell safety audits, enforce effective communication and handover protocols, and ensure strict compliance with observation requirements for vulnerable prisoners. ”

    Source location

    Steven HART · 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

    Strengthen shift handovers through clearer risk-information sharing expectations and allocated time for comprehensive handovers.

    Verbatim wording from the response

    “Handover procedures have also been strengthened to ensure that vital information is communicated effectively. Staff are supported through clearer expectations in relation to information sharing when there is evidence of a prisoners change to risk or presentation. Time has been allocated to facilitate comprehensive handovers between shifts, particularly in relation to those who are being supported by the Assessment, Care in Custody and Teamwork (ACCT) process.”

    Source location

    Response from HM Prison & Probation Service
    Page 2 · response
    Published 3 October 2025

    Open published response

  5. 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 mandatory or refresher training on information handover during detainee booking

    Wider context from the report

    “5. Lack of refresher or mandatory annual training for police officers in relation to information to be passed to the custody officers during the booking in procedure. I am told that there is no specific mandatory training for police officers on the information expected of them at the custody suite desk during the booking in procedure, but that trainee police officers are now given training on constant supervision as part of their introduction to the custody suite. I am concerned that police officers are regularly handing over to custody officers without any mandatory training or refresher training on the subject, which leaves the information that they decide to pass over open to discretion. Training an officer once, at the beginning of their career, leaves the door open to the development of bad practice and the fallibility of human memory. This gives rise to a risk of future death for detained persons if pertinent information is omitted, for example health or intoxication information. ”

    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

    Review the booking-in sheet and create holding-area posters reminding officers to report illness, injuries and intoxication to the Custody Sergeant.

    Verbatim wording from the response

    “Future work”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 8 · 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

    Design force screen savers and deliver annual local CPD reinforcing information, roles and responsibilities when booking detainees into custody.

    Verbatim wording from the response

    “Force screen savers will be designed by the Custody Lead, incorporating key and additional information they must provide to a Custody Sergeant when booking in a detained person into custody, this will be supported by a yearly CPD package and delivered locally by Force Inspectors/Detective Inspectors again reminding officers around their role and responsibilities.”

    Source location

    Response from South Yorkshire Police and Humberside Police
    Page 8 · response
    Published 4 April 2024

    Open published response

  6. Worcestershire

    AI-generated summary

    Saul Richard THOMAS · 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

    Saul Richard Thomas died in his cell at HMP Hewell on 19 May 2019 after being transferred there from HMP Birmingham, where he had expressed paranoid thoughts and was undergoing psychiatric assessment. The concerns included failures to open an ACCT document, communicate important mental-health information during the prison transfer, and adequately assess and manage his mental health at HMP Hewell; the inquest found that these failures probably or possibly caused or contributed to his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of inter-prison handovers to include important clinical information

    Wider context from the report

    “(2) In the questionnaire which formed part of their conclusion, the jury found that the unsatisfactory handover about Mr. Thomas provided by HMP Birmingham to HMP Hewell possibly caused or contributed to his death. I heard evidence from a senior member of staff at HMP Birmingham that (a) prison staff there should have alerted their counterparts at HMP Hewell to the fact that Mr. Thomas had been undergoing psychiatric assessment within the Inpatients Unit there; and (b) that this was still a concern which needed to be looked into. I was concerned to hear that, whilst this failing has been recognized by HMP Birmingham, no action has been taken to ensure that it will not be repeated. Until action is taken to ensure that handovers between prisons include such important information, there remains a risk of similar deaths occurring in the future. ”

    Source location

    Saul Richard THOMAS · 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

    Implement a healthcare handover process for prisoners transferring from HMP Birmingham to another establishment.

    Verbatim wording from the response

    “With regard to transfer procedures, a new process is now in place at HMP Birmingham for when prisoners who are being supported by healthcare, including mental health services, are being transferred to another establishment. As soon as it is known a prisoner is transferring, the healthcare team are required to make contact with the receiving prison. If this is not possible then the matter is escalated to the healthcare manager and duty Governor who are then required to ensure a handover takes place before they leave their shift. In addition to this, on the day of the transfer reception staff are required to call the receiving reception manager to notify them of a new arrival transferring from a healthcare unit.”

    Source location

    2021-0423-Response-from-HMPPS_Published
    Page 2 · response
    Published 22 December 2021

    Open published response

  7. Mid Kent and Medway

    AI-generated summary

    Caden Stewart · 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

    Caden Stewart, aged 16, became unwell after weightlifting in custody and was later found collapsed and unresponsive in his cell. He was diagnosed with a brain haemorrhage, underwent surgery, and died at King’s College Hospital. The principal concerns were inadequate reporting and recording procedures and insufficient communication between prison officers and healthcare staff, resulting in healthcare failing to attend his requests to be seen.

    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 healthcare waiting status during handover

    Wider context from the report

    “3. The wing officer in charge did not check whether Caden had been seen by healthcare at any stage over the following hours nor did he inform his successor on handover that Caden was waiting to see healthcare and had not been seen ”

    Source location

    Caden Stewart · 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

    Use daily residential roll books, guidance prompts and NOMIS records to capture healthcare requests, follow-up actions and relevant wellbeing information for staff sharing.

    Verbatim wording from the response

    “To ensure improved and effective information sharing regarding a prisoner’s well-being, in September 2021 the Young People Services Team introduced daily roll books onto the residential areas which record the amount of time each young person spends in various activities. The logs provide for comments to be added and ‘guidance prompts’ are now in place which outline the importance of providing this information so that it is available to all staff. The guidance prompts also explain the type of information staff should record, including where a young person has made a request to see healthcare. A Notice to Staff detailing the use of the roll books was issued to ensure all staff are aware of the need to record information about a young person in custody.”

    Source location

    2021-0328-Response-from-HMPPS_Published
    Page 1 · response
    Published 13 October 2021

    Open published response

  8. Lancashire and Blackburn with Darwen

    AI-generated summary

    Andrew Patrick Jones · 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 Patrick Jones, a 37-year-old male prisoner, died after being transferred from a vulnerable-prisoner wing, unlawfully segregated and deprived of healthcare assessment, basic amenities and prescribed medication. The report identified concerns about inadequate risk assessment and communication, the absence of effective personal-officer support and transfer protocols, inconsistent medication systems, unlawful segregation, and failures relating to adjudication and monitoring. The expert psychiatric evidence stated that these factors created the “perfect storm”, and the jury concluded that the prison regime contributed to the death and added a rider of Neglect.

    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 receiving wings with relevant prisoner risk information during transfer handover

    Wider context from the report

    “The only handover that was given by SO ████████ on the RSU to the receiving wing was that there were no non-associates and Andrew Jones was behind his door on basic regime pending adjudication. SO ████████ was unaware that Andrew Jones had been on an ACCT until after he had been sent to C Wing. ”

    Source location

    Andrew Patrick Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Manchester City

    AI-generated summary

    Tomasz Nowosad · 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

    Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

    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 maintain auditable cross-shift handover of relevant information

    Wider context from the report

    “5 11 It is suggested that there should be an auditable process of ensuring that all appropriate information is handed over between different shifts of GMMH and HMPS staff so that there is a continuity and consistency of available information ”

    Source location

    Tomasz Nowosad · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  10. 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

    Lack of clear and detailed handover between arresting and transporting officers

    Wider context from the report

    “3. Adam Harris was not transported by the Arresting Officer but by Police Officers operating a divisional van. There was no evidence of a clear and detailed handover between the Arresting Officer and the Transporting Officers. One of the Transporting Officers described the role they played as a police taxi service; ”

    Source location

    Adam Harris · Prevention of Future Deaths report
    Page 1 · 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

    Deliver Transportation of Detained Persons procedure content in the foundation course for all newly appointed Student Police Officers.

    Verbatim wording from the response

    “From August 2019 the contents of the revised “Transportation of Detained Persons” procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment. There are also components of the policy currently being reviewed with a view to being incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually. It is anticipated that the revised training will commence in Autumn / Winter 2019.”

    Source location

    2019-0247-Response-from-Greater-Manchester-Police
    Page 2 · response
    Published 9 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

    Review and incorporate relevant transportation-procedure components into annual Personal Safety Training for operational police officers and staff.

    Verbatim wording from the response

    “From August 2019 the contents of the revised “Transportation of Detained Persons” procedure features in the initial Student Police Officer foundation training course delivered to all Student Police Officers on appointment. There are also components of the policy currently being reviewed with a view to being incorporated into the Personal Safety Training courses which all operational Police Officers and staff undertake annually. It is anticipated that the revised training will commence in Autumn / Winter 2019.”

    Source location

    2019-0247-Response-from-Greater-Manchester-Police
    Page 2 · response
    Published 9 September 2019

    Open published response
Back to top

Data last updated 7 September 2026