2 Feb 2026 Scott Darren TAYLOR · Prevention of Future Deaths report Essex
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Concerns raised 1
Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
Essex Police
Standardise Acute Behavioural Disturbance training for regular officers and Special Constables across initial and refresher training.
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Scott Darren TAYLOR · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Scott Darren Taylor died at Basildon Hospital on 13 August 2022 following multiorgan failure and rhabdomyolysis associated with cocaine use, physical exertion, prone restraint and Neuroleptic Malignant Syndrome. The report raised concerns about inconsistent ambulance response categorisation for acute behavioural disturbance with active restraint, terminology and training, police training, and the removal of restraints during conveyance.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Discrepancy in Acute Behavioural Disturbance recognition and alert training for Police Officers and Special Constables
Wider context from the report “a. Whilst it was not causative of Mr Taylor’s death, there appears to be a discrepancy in the training for Police Officers and Special Constables in the potential recognition and actions for Acute Behaviours Disturbance . Special Constables are a valuable resource for police forces and may often be first on scene as in this case and should receive the same training in the potential recognition and alert of potential life-threatening conditions.
” Source location Scott Darren TAYLOR · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Standardise Acute Behavioural Disturbance training for regular officers and Special Constables across initial and refresher training.
Verbatim wording from the response “In relation to ABD, you noted that Special Constables may not have received the same depth of training as regular officers. Essex Police acknowledges the importance of ensuring that all officers, regardless of role, are equipped to identify life-threatening medical emergencies and respond consistently. As a result, all officers—regular and Special Constabulary—now receive the same level of training in relation to ABD.” Source location Response from Essex Police
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Concerns raised 2
Lack of police training for mental health-related incidents involving illicit substance use View source Failure of police training on ambulance conveyance for s.136 detainees View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Kaine Regan FLETCHER · Prevention of Future Deaths report
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Report summary
Kaine Regan FLETCHER, a 26-year-old man with paranoid personality disorder and a history of substance misuse, died on 3 July 2022 after restraint by police, developing rhabdomyolysis, multi-system organ failure and cardiac arrest. The report raises concerns about the lack of joined-up policies and cross-sector working on acute behavioural disturbance and section 136 detentions, police and ambulance conveyance practices and training, the availability of out-of-hours street triage, and gaps in services for people with combined mental health and substance misuse conditions.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of police training for mental health-related incidents involving illicit substance use
Wider context from the report “4. Police training on s.136 MHA 1983 detention and mental health
I heard evidence that there is no national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. Further, that there is no specific training in relation to persons who are struggling with their mental health and who may be under the influence of illicit substances . I am concerned that training in the area of mental health generally is lacking , which is impacting upon the approach of the police officers dealing with mental health related incidents.
” Source location Kaine Regan FLETCHER · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of police training on ambulance conveyance for s.136 detainees
Wider context from the report “3. Police use of an ambulance as the mode of conveyance for s.136 detainees
I heard evidence that the correct mode of conveyance for persons detained under s.136 MHA 1983 is an ambulance, save in exceptional circumstances (e.g. where the detained person’s behaviour means it would be inappropriate, or where the wait for an ambulance would exceed 30 minutes).
I also heard evidence, that in the last 12 months an ambulance was called by the police in only 50% of s.136 detentions. Of that 50% in which an ambulance was called, an ambulance only attended on 50% of occasions (so 25% of the total detentions).
Of the nine police officers that gave evidence to me in this inquest on s.136 matters, none of them knew about the police policy on calling an ambulance to convey a s.136 detainee .
Two of the officers knew, anecdotally, that an ambulance was the preferred method of conveyance, but their evidence was that it was common for an ambulance to take well over 30 minutes or not turn up at all.
I am concerned that:
• There is a training issue within the police in relation to s.136 detentions and the correct mode of conveyance . Either officers do not know that they should call an ambulance, or they are ignoring their training/the instructions that they are given. This is born out in the statistics above.
• There is a response issue on the part of EMAS. This may, in part, be explained by the policy/service level agreement confusion within EMAS.
” Source location Kaine Regan FLETCHER · Prevention of Future Deaths report
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25 Mar 2025 Oladeji Adeyemi Omishore · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Inadequate response officer training on de-escalation and taser deployment tactics for subjects with mental ill-health View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
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Oladeji Adeyemi Omishore · 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
Oladeji Adeyemi Omishore died on 4 June 2022 after being tasered during an incident involving police officers on Chelsea Bridge and then entering the River Thames; his medical cause of death was complications arising from drowning. The report identified concerns about the recording and transmission of mental health information by call handlers and dispatchers, and about training for responding officers in tactical options before taser deployment.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate response officer training on de-escalation and taser deployment tactics for subjects with mental ill-health
Wider context from the report “11. That training for response officers may require review in relation to tactical options used to de-escalate prior to taser deployment , in appropriate circumstances, given the increased use of taser in black men with mental health issues; and in particular, training in relation to deploying with taser drawn and pointed with accompanying commanding language where the subject may be suffering with mental ill-health .
” Source location Oladeji Adeyemi Omishore · Prevention of Future Deaths report
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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 Embed de-escalation techniques and BUGEE conflict-management skills within PPST and Taser training, including scenario-based assessment of mental distress and vulnerable persons.
Verbatim wording from the response “The foundation of all officer training begins with the Personal & Public Safety Training (PPST), which equips officers with essential skills in the use of force, their powers under the law, and de-escalation techniques. These are delivered comprehensively during an officer’s initial training and are reinforced annually through mandatory refresher sessions.” Source location Response from Metropolitan Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a Taser-specific Community Scrutiny Panel and feed its review of incidents into officer training.
Verbatim wording from the response “In 2024 the MPS launched a Taser specific Community Scrutiny Panel to allow Taser incidents and use to be viewed by a panel from the community and feed back into training. This has led towards the MPS being more transparency and accountable. The views of the panel are fed back to the officer. This is particularly powerful feedback as it informs the officer as to how a jury may perceive their actions and use, particularly when the justification has not been properly explained.” Source location Response from Metropolitan Police
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review Taser activations through the dedicated Taser use review system and address use falling outside training or justification.
Verbatim wording from the response “The MPS also have a comprehensive Taser use review system where a dedicated team review every Taser activation, any Taser use on under 18’s, at height, subjects running away, in custody, and over 65years. In addition to this the team review all uses on the Basic Command Units (BCU) each month (meaning each BCU has all their Taser use reviewed once a year).” Source location Response from Metropolitan Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Frontline officers, rather than communication officers, are responsible for awareness of force against black men with mental-health issues.
Verbatim wording from the response “However, please note that it is more for officers on the frontline to be appraised and aware around use of force against black men with mental health issues than communication officers, who follow a Standard Operating Procedure when dealing with calls, irrespective of race/gender.” Source location Response from Metropolitan Police
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30 Oct 2024 Sebastian Benjamin OLIVER · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Shortcomings in training for incidents involving fluctuating or lacking capacity and absconding from treatment centres View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
West Midlands Police
Provide mandatory Right Care, Right Person training to Force Contact staff and relevant frontline officers, including decision-support materials and phase-specific training.
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West Midlands Police
Develop a hospital-absconder question set and related Force Contact training to gather information supporting deployment decisions without treating medical capacity as determinative.
View source
West Midlands Police
Update training lesson plans and inputs on the Mental Capacity Act, capacity assessments and partner-agency assessments for all staff.
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West Midlands Police
Reinforce through training that staff must re-THRIVE and record a full rationale when recommending non-police attendance.
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Sebastian Benjamin OLIVER · Prevention of Future Deaths report
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Report summary
Sebastian Benjamin Oliver was found unresponsive on 29 November 2023 after sustaining an incised wound to his left hand while climbing a spiked fence under the influence of drugs, and he later died in hospital. The report identified concerns about West Midlands Police closing a safe-and-well-check log after Mr Oliver absconded from hospital, relying on an earlier capacity assessment despite a later assessment that he lacked capacity, and about shortcomings in training and communication with ambulance staff.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Shortcomings in training for incidents involving fluctuating or lacking capacity and absconding from treatment centres
Wider context from the report “3. WMAS notified West Midlands Police ("WMP") and requested a "safe and well check". After determining he was not at the last known location, the decision was made by officers of WMP to close the log because WMAS had earlier deemed him to have capacity (following the 22:18 call).
4. However, the decision to close the log was an error - as a person's capacity can fluctuate, it was inappropriate for WMP to rely upon a past capacity assessment taken hours earlier in the evening, particularly when a more recent capacity assessment indicated that he lacked capacity and where WMAS were concerned enough to request a "safe and well check".
5. I stress that the evidence was clear at inquest that even if WMP had not closed the log, they may not have been able to find Mr Oliver as it was not known where he went in the two hours or so after he left hospital, before being recorded on CCTV at 02:55 at ████████, and being subsequently found unresponsive at 06:21. On the balance of probabilities therefore, it cannot be said that Mr Oliver would have been found had the log not been closed.
6. However, I am concerned that the decision to not seek clarification from WMAS as to Mr Oliver's capacity represents shortcomings in training and/or a failure to ensure that WMP properly and effectively communicate with medical colleagues in WMAS when dealing with incidents where patients have fluctuating or lack capacity and abscond from treatment centres. It is not clear whether this was a "one-off" issue localised to a specific officer, or whether it represents a larger or institutional issue.
7. It is easy to anticipate a similar situation occurring in the future which leads to a death that is preventable, particularly those involving vulnerable persons and those lacking capacity.
” Source location Sebastian Benjamin OLIVER · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide mandatory Right Care, Right Person training to Force Contact staff and relevant frontline officers, including decision-support materials and phase-specific training.
Verbatim wording from the response “Additional training has been provided to WMP Force Contact Call Handlers to ensure that the right deployment decisions are made when calls are received from members of the public or partners. This was in the form of a ‘Blackboard’ hybrid learning package containing informative videos, theory and knowledge checks in addition to a ‘flowchart’ decision tree to support Force Contact’s decision making; this is easily accessible to all both via a link within the ControlWorks (WMP’s command and control system) and within the WMP Intranet page. This includes consideration as to whether the call relates to an Article 2 (immediate risk to life) or Article 3 (immediate threat of serious harm) issue, and where these are present to deploy a police resource only where there is a clear policing role.” Source location Response from West Midlands Police
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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 hospital-absconder question set and related Force Contact training to gather information supporting deployment decisions without treating medical capacity as determinative.
Verbatim wording from the response “The following measures will also be introduced within the Force Contact environment as part of the continuous improvement of the Force Contact function service within WMP. These will focus on supporting individual decision makers who are required to make decisions in cases such as Mr Oliver’s where there is a question of capacity.” Source location Response from West Midlands Police
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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 training lesson plans and inputs on the Mental Capacity Act, capacity assessments and partner-agency assessments for all staff.
Verbatim wording from the response “(vii) Training lesson plans and inputs to ensure: that the Mental Capacity Act, capacity assessments and partner agency assessments are inputted to all staff.” Source location Response from West Midlands Police
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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 Reinforce through training that staff must re-THRIVE and record a full rationale when recommending non-police attendance.
Verbatim wording from the response “(viii) Training to reinforce to staff to re-THRIVE: and a complete a full rationale if recommending non-Police attendance.” Source location Response from West Midlands Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police cannot determine deployment solely from capacity status because officers are not medically trained to assess its implications.
Verbatim wording from the response “(i) Capacity: Vulnerability Desk to support in implementing training within Force Contact that creates a question set for Contact Handling in relation hospital absconders to assist in gaining all the appropriate information to aid decision making. The term ‘capacity’ should NOT bear relevance to WMP’s decision making on an individual as we are not medically trained to determine the potential outcome for an individual who does or does not have capacity. We cannot definitively state that we would deploy in all instances where an individual lacks capacity or not deploy if they do. Therefore, it is more appropriate to move away from this terminology so that it is not an unnecessary focal point of decision making.” Source location Response from West Midlands Police
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2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission College of Policing Department of Health and Social Care Greater Manchester Police Home Office NHS England North West Ambulance Service NHS Trust Trafford Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
College of Policing
Create and provide a bespoke e-learning training package on responding to mental health incidents for all police forces.
View source
Greater Manchester Police
Deliver mandatory mental health awareness training to officers and relevant contact-centre staff.
View source
Greater Manchester Police
Provide RCRP assessment and decision-making training through role-specific courses and an accredited e-learning package.
View source
Greater Manchester Police
Provide clinical mental-health advice, incident-call reviews and GP referrals through the Mental Health Tactical Advice Service.
View source
Greater Manchester Police
Monitor and review RCRP assessment decisions and adverse outcomes, reporting findings to senior command and partner governance.
View source
Greater Manchester Police
Enhance and introduce quality-assurance systems supporting RCRP decision-making and continuing professional development.
View source See 3 more actions
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Michael Sean Heath · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” Source location Michael Sean Heath · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and provide a bespoke e-learning training package on responding to mental health incidents for all police forces.
Verbatim wording from the response “The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ (RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice (APP) and an associated toolkit. The College of Policing also works closely with the National Police Chiefs’ Council which is supporting forces in the development and implementation of this policy. The toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning training package, which is available to all police forces.” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mandatory mental health awareness training to officers and relevant contact-centre staff.
Verbatim wording from the response “Mandatory Mental Health Awareness (GMP)
In GMP, this is delivered in accordance with the CoP Approved Professional Practice (APP) for policing duties. The introduction to this APP states: “All police decision making on the most appropriate course of action under any circumstances should be guided and structured using the national decision model (NDM). Decision making concerning health care matters should be made by clinically trained professionals and not police officers”. Although police officers and staff are not expected to be able to identify the specific symptoms of mental ill health or learning disabilities or attempt to diagnose illness, it is important that their training enables them to recognise indicators of mental health problems so that these can be taken into consideration. This recognition can occur at any point in their interaction with people.” Source location Response from GMP
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide RCRP assessment and decision-making training through role-specific courses and an accredited e-learning package.
Verbatim wording from the response “Call handlers and Crime Recording and Resolution Officers (CRRO) will use the RCRP Assessment Toolkit and refer to GMP service standards and ask further questions in order to be satisfied as to the exact nature of the call and assess the requirement for police deployment. They are guided to recognise any identified risk and if necessary be ‘professionally curious’ to ensure understanding. GMP’s Incident Response Policy requires that, in order to ensure an appropriate response to the contact’s needs, incident priority is determined by a THRIVE risk assessment³, response grading in accordance with the THRIVE assessment and a consideration of the GMP Vulnerability Assessment Framework (VAF). The aim is to ensure that the appropriate police response for every call is initiated from the outset.” Source location Response from GMP
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide clinical mental-health advice, incident-call reviews and GP referrals through the Mental Health Tactical Advice Service.
Verbatim wording from the response “GMP’s Mental Health Co-Ordination Unit (MHCU) have confirmed that a 3.5 hours long Mental Health Awareness input has been delivered face to face to over 2500 officers during 2024 and this has included a sixty minute input from the Clinical Lead of the Mental Health Tactical Advice Service (MHTAS), based in the Force Contact Centre to include common presentations and risks. MHTAS support officers making decisions relating to mental health concerns and will also review any mental health related incident/call for service at the request of a FCCO supervisor. MHTAS forward a GP referral for every individual they review.” Source location Response from GMP
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Monitor and review RCRP assessment decisions and adverse outcomes, reporting findings to senior command and partner governance.
Verbatim wording from the response “In respect of Greater Manchester, learning from other forces who had already implemented RCRP was that staff and officers may find it difficult to make the decision that the police will not be attending a call. This is because they may be concerned about the consequences of adverse outcomes or criticism of their decision making, when not attending. It is accepted that these are incredibly difficult decisions to make, especially in a pressurised environment and when complex legislation comes into play. The RCRP assessment tool is there to support staff to evidence their decision making and will continue to be subject to review and monitoring by GMP and its partners.” Source location Response from GMP
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance and introduce quality-assurance systems supporting RCRP decision-making and continuing professional development.
Verbatim wording from the response “• Training and development strategy and evaluation criteria defined” Source location Response from GMP
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Verbatim wording from the response “Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council, you will appreciate that I am unable to specifically address these with a respective timetable for action.” Source location Response from Trafford Council
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College of Policing and Greater Manchester Police are responsible for addressing the specific police working practices raised.
Verbatim wording from the response “Firstly, I should advise that police forces are operationally independent and, as such, it is for the College of Policing and Greater Manchester Police (GMP) to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Heath.” Source location Response from Home Office
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Policing, advocacy, communication, and interagency information access should be addressed by the other individuals and organisations named in the report.
Verbatim wording from the response “We note that your Report has also been addressed to individuals including the Home Secretary and the Minister of Policing, along with organisations including the Greater Manchester Mental Health NHS Foundation Trust, North West Ambulance Service, Greater Manchester Police and Trafford Council. It is appropriate that these individuals and organisations address some of the matters of concern, namely around those issues relating to policing, advocacy and communication and access to information between the local agencies and staff involved in Michael’s care. NHS England will review and consider carefully the other responses in due course.” Source location Response from NHSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.
Verbatim wording from the response “Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.” Source location Response from NWAS
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Police mental-health call training is assigned to the Home Office, Greater Manchester Police and the College of Policing.
Verbatim wording from the response “With regard to your concern around training for police officers in dealing with calls of a mental health nature, I would expect this to be addressed by the Home Office, Greater Manchester Police and the College of Policing in their responses to you, as policing and police training falls under their remit.” Source location Response from DHSC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Training police officers to assess mental-health calls and determine police involvement sits outside CQC’s remit.
Verbatim wording from the response “We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Greater Manchester Police and the College of Policing are better placed to address police mental-health assessment and involvement concerns.
Verbatim wording from the response “We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.” Source location Response from CQC
Open published response
Concerns raised 1
Failure to ensure police officers understand mental health issues and referral information requirements View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Ryan Louis Ouslem · 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
Ryan Louis Ouslem was found deceased at home on 1 August 2022 after previously posting a Facebook message that raised concerns for his welfare and indicated that his flat was unsafe to enter. The report raises concerns about police mental-health training and assessment, the sharing of relevant information between police and mental-health services, and the lack of joint training under new working arrangements.
Read the report on judiciary.uk
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure police officers understand mental health issues and referral information requirements
Wider context from the report “The inquest heard evidence from a Street Triage practitioner who was embedded with the police on the 29/07/22. She explained that they are reliant on the police to share relevant information, for example from the police CAD system. In this case not all relevant information was passed to the mental health practitioner in a timely manner.
An SPFT witness stated that it was not for them to provide training to the police and that she had not been on any cross-service training.
I was informed that a new system of working with the police is being introduced this will be called the ‘Rapid Response Service’ and mental health workers will no longer be embedded with the police.
SPFT has provided me with the way the new system is anticipated to function and this has been helpful in understanding the changes. No policy documents yet exist for this system and an SPFT witness told me that how information is to be shared between them and the police service is yet to be ironed out. Some of this service will not be dissimilar to the Street Triage service.
I am concerned because this new approach under the ‘Right Care, Right Person’ policy will still need police officers to understand mental health issues in order to know when to pass matters on for mental health services to deal and what information to provide .
Despite the significant change of working arrangements there does not appear to have been any joint training undertaken; nor am I informed that any is planned. I am concerned that the importance of sharing all relevant information will not be understood unless each organisation understands what information to provide to the other or what questions to ask.
” Source location Ryan Louis Ouslem · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Joint training with SPFT is not considered workable because its cost and logistical requirements are disproportionate at this stage.
Verbatim wording from the response “We have carefully considered whether joint training with SPFT could provide anything additional which could assist officers when referring matters and providing information to them, however we do not believe it is workable step and the cost and logistics of doing so would not be proportionate at this stage.” Source location Response from Sussex Police 2
Open published response
Concerns raised 1
Lack of police officer training in recognising mental health conditions and their behavioural effects View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
South Yorkshire Police
Deliver mental-health awareness training to frontline officers, including recognition of mental-health problems and crisis indicators.
View source
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of police officer training in recognising mental health conditions and their behavioural effects
Wider context from the report “2. Lack of training in First Aid or Personal Safety courses for police officers in relation to recognising the signs and symptoms of mental health conditions and acute mental health crisis. Specifically, when this may be impacting upon the behaviour of the detained person and whether they require medical assistance from a hospital.
I have been told that officers are trained in methods of communication with persons who are suffering from mental health episodes, but not how to recognise the symptoms . There is training on ABD, and I am not concerned about the officers’ ability to respond to persons with suicidal ideation. Accepting that police officers are not medical professionals, I am concerned that there is no guidance on recognition of symptoms of mental health conditions falling short of crisis (in particular the way in which this may affect behaviour) and appropriate management, then detained persons suffering from a mental health episode, or with pre-existing mental health conditions, may be at risk of future death.
” Source location Matthew Terrill · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver mental-health awareness training to frontline officers, including recognition of mental-health problems and crisis indicators.
Verbatim wording from the response “Mental Health training was rolled out to all front line officers via Street Skills in 2018. This was developed and delivered with partners and individuals with lived experience. This gave officers guidance on recognising sign and symptoms of mental health issue including those falling short of a crisis.” Source location Response from South Yorkshire Police and Humberside Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing acute behavioural disturbance and mental-health training means generic mental-health conditions will not be added to first-aid training.
Verbatim wording from the response “However, in both Personal Safety Training (PST) and First Aid training since 2014 officers have received an input on Acute Behavioural Disturbance (ABD) and on how to recognise signs and symptoms in both theory and practice.” Source location Response from South Yorkshire Police and Humberside Police
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Force-wide mental-health CPD cannot be delivered before 2025 because current continuing-professional-development capacity is full.
Verbatim wording from the response “South Yorkshire Police CPD is currently booked up until December 2024, a further mental health CPD event will be considered in CPD training from early 2025 where we will look to deliver this force wide.” Source location Response from South Yorkshire Police and Humberside Police
Open published response
25 Oct 2023 Carl FULLALOVE · Prevention of Future Deaths report Cheshire
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Concerns raised 3
Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks View source ABD training failing to support reliable identification of underlying medical conditions and referral in dynamic settings View source Rigid ABD training focused on specific symptoms and failing to support recognition of other signs View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Carl FULLALOVE · 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
Carl Fullalove was arrested after being observed jumping on cars, behaving bizarrely and appearing to be under the influence of a substance. He was placed in prone restraint during a search in custody, became non-responsive and suffered cardiac arrest, and subsequently died in hospital. The principal concerns were that signs of acute behavioural disturbance or illness were not recognised, the risks of prone restraint and stimulant drugs were not sufficiently considered, and training did not adequately address calming intervention in an upright position.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of ABD training and recognition processes to identify nuanced signs in drug intoxication and consider prone-restraint risks
Wider context from the report “(1)Whilst the jury did not make any finding of acute behavioural disturbance (ABD) in this case, much evidence was heard about the training in identification of the signs and symptoms. National training of police officers on the identification of ABD is focused on a triad of warning flags being, hot to touch, exhibiting constant or near constant activity and extreme agitation or aggression. Some evidence identified that Carl Fullalove did not exhibit these triad symptoms but did exhibit other nuanced symptoms in the long list delivered in training. It was evident that his symptoms were not recognised as ABD due to drug intoxication, and that the consequential risks associated with prone restraint were not therefore considered. Prone restraint ultimately led to his death. There were six experts providing evidence to the inquest two of whom identified that Carl would not have died had he been recognised as unwell at the point of arrest and assessed by a health care practitioner. Such attention would have provided a calming intervention for his heart rate and breathing prior to being placed in prone restraint, which exerted additional pressure on his ability to breath freely.
” Source location Carl FULLALOVE · Prevention of Future Deaths report
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 ABD training failing to support reliable identification of underlying medical conditions and referral in dynamic settings
Wider context from the report “(3)Significant training on ABD had been delivered by Cheshire Constabulary through the College of Policing Personal Safety Training package module, the key to which was to identify an underlying medical condition to refer to a health care practitioner. That may be a lot to expect of police officers in a dynamic fast paced setting. The use of the term ABD may be a distraction.
” Source location Carl FULLALOVE · Prevention of Future Deaths report
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 Rigid ABD training focused on specific symptoms and failing to support recognition of other signs
Wider context from the report “(2)A research paper before the inquest, namely ‘Consensus on Acute Behavioural Disturbance in the UK, September 2023 recommends that the focus remain on the triad of warning signs. ABD is clearly difficult to distinguish from drug intoxication by a non-medical practitioner. The rigidity of the training with focus on specific symptoms can cause police officers to miss other signs. The Superintendent, and head of ‘Protecting Vulnerable People’ for Cheshire accepted that with hindsight the use of prone restraint was inadvisable in this case.
” Source location Carl FULLALOVE · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish the revised First Aid Learning Programme outcome requiring officers to recognise signs and symptoms of acute behavioural disturbance.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and” Source location Response from College of Policing
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and update Public and Personal Safety Training to cover ABD presentation and causes, de-escalation, restraint risks, medical assistance, monitoring, and scenario-based decision-making.
Verbatim wording from the response “The College of Policing have designed and developed a new Public and Personal Safety Training (PPST) package for all police officers with the emphasis on de-escalation. It is twelve hours, scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and de-briefing decisions. Some forces have already implemented the new training package, and all forces are to go live with this training in April 2024. From the evaluation of the training pilot, early, statistically significant data shows a reduction in police use of force incidents. The updated training will include a recently updated training package for ABD.” Source location Response from College of Policing
Open published response
3 Jul 2023 Andre Felipe Mendes Moura · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Lack of formal training on suspected feigned unresponsiveness View source Failure of ABD training to enable recognition in real-life settings View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
College of Policing National Police Chiefs’ Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
College of Policing
Publish the revised First Aid Learning Programme with a learning outcome requiring recognition of acute behavioural disturbance signs and symptoms.
View source
College of Policing
Implement scenario-based Public and Personal Safety Training covering ABD recognition, de-escalation, containment, medical emergencies and immediate medical assistance.
View source
College of Policing
Use observed scenario assessments, knowledge checks and pass-or-fail decisions to test officers’ responses to acute behavioural disturbance.
View source
College of Policing
Publish the revised acute behavioural disturbance training package.
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AI-generated summary
Andre Felipe Mendes Moura · 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
Andre Moura died on 7 July 2018 after suffering cardiac arrest in a police vehicle while under arrest and being transported following a significant struggle. The report identified concerns about officers’ recognition and training in acute behavioural disturbance, use of objective responsiveness checks, the safety officer role, and the absence of body-worn camera recording during escort.
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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 training on suspected feigned unresponsiveness
Wider context from the report “4. Many of the officers who gave evidence indicated that they believed that Mr Moura was feigning his lack of responsiveness. This was despite the fact that there was very limited evidence of officers carrying out the recognised AVPU checks. Officers relied on their own perceptions rather than AVPU. An officer who did carry out AVPU did not clearly share his lack of responsiveness with other officers. The Inquest heard that there is no formal training on what officers should do if they believe a prisoner under arrest is feigning unresponsiveness . Clarification and enforcement of the need for objective use of AVPU may well prevent subjective assessments leading to erroneous and potentially fatal conclusions that a prisoner is feigning lack of responsiveness;
” Source location Andre Felipe Mendes Moura · Prevention of Future Deaths report
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 ABD training to enable recognition in real-life settings
Wider context from the report “1. During the course of the Inquest, evidence was heard about the understanding and training in relation to Acute Behaviour Disturbance (ABD). All of the officers who had received their College of Policing Personal Safety Training had been trained on the ABD module within that package. However it was clear that the training package had not achieved the objective i.e. to recognise ABD in a real life setting . The Inquest heard that ABD is an umbrella term and not all of the symptoms need to be present for someone to be suffering from ABD. It was clear from the officers’ evidence that the videos played in the training particularly of extreme examples of ABD had led them to not consider or recognise ABD in this situation . The Inquest heard that it could be difficult to recognise ABD in a dynamic situation but the training was there to ensure officers considered it in situations where it was a possible explanation for behaviour seen by officers. An emphasis on the nuances and less on extreme examples may assist in improving the recognition of ABD;
” Source location Andre Felipe Mendes Moura · Prevention of Future Deaths report
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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 Publish the revised First Aid Learning Programme with a learning outcome requiring recognition of acute behavioural disturbance signs and symptoms.
Verbatim wording from the response “In 2020, the College of Policing commenced a national working group to update the First Aid Learning Programme (FALP). The review that took place considered recommendations made by Coroners and the IOPC, including the detail of learning outcomes on Acute Behavioural Disturbance and treatment of head injuries.” Source location Response from College of Policing
Open published response
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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 scenario-based Public and Personal Safety Training covering ABD recognition, de-escalation, containment, medical emergencies and immediate medical assistance.
Verbatim wording from the response “The new Public and Personal Safety Training (PPST) for all police officers has recently been developed with the emphasis on de-escalation. It is a scenario-based method of delivering training and is focused on learning, decision making, understanding decisions and debriefing decisions. The updated training will include identification of the signs and symptoms of ABD and management of the incident with the focus now being on de-escalation and ‘contain rather than restrain’, where officers suspect a person to be experiencing ABD. There will also be an emphasis on treating ABD as a medical emergency and seeking immediate medical assistance.” Source location Response from College of Policing
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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 observed scenario assessments, knowledge checks and pass-or-fail decisions to test officers’ responses to acute behavioural disturbance.
Verbatim wording from the response “The new PPST is designed to be an interventionalist style of training delivery. The trainers observe the students managing the scenarios. The training is stopped at regular intervals when the trainers will test the knowledge of the students and get the students to explain the rationale for their decisions. PPST is a pass or fail course.” Source location Response from College of Policing
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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 Publish the revised acute behavioural disturbance training package.
Verbatim wording from the response “The new PPST training implementation went live in 2023 and forces are required to have implemented or be in the process of implementation by April 2024. The revised ABD training package will be published mid-September 2023.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing ABD guidance is sufficient; officers should treat displayed symptoms consistently even when they suspect feigned unresponsiveness, so no approach change is supported.
Verbatim wording from the response “The College guidance does not support any change in approach where officers may believe that someone is feigning a lack of responsiveness. All ABD guidance is focused on how to treat the displayed symptoms and should be followed regardless of any suspicions that symptoms are feigned.” Source location Response from College of Policing
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The College of Policing is responsible for addressing the four concerns concerning personal safety and Acute Behaviour Disturbance training.
Verbatim wording from the response “I note you set out five areas of concern, four of which focus on College of Policing Personal Safety Training, with particular focus on Acute Behaviour Disturbance (ABD). I am aware the College of Policing have written to you separately to address these points and have shared the timeframes for implementation of new Public and Personal Safety Training and revised ABD training.” Source location Response from National Police Chief's Council
Open published response
23 May 2023 Daniel LYLE · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 2
Insufficient focus in police officer training on symptoms and presentation of mental health conditions View source Insufficient focus in police officer training on practical strategies for decision making in mental health situations View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Daniel LYLE · 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
Daniel LYLE, who suffered from paranoid psychosis, experienced a psychotic episode on 20 March 2020 and climbed approximately 30 feet into a tree while displaying paranoid and delusional beliefs. He fell from the tree, sustained fatal head and chest injuries, and died despite resuscitation efforts. The principal concern was that police training was not sufficiently focused on understanding mental health symptoms and presentation, or on practical strategies to support decision-making during mental health crises.
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× 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 focus in police officer training on symptoms and presentation of mental health conditions
Wider context from the report “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on:
(a) an understanding of the symptoms and presentation of mental health conditions ;
(b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.
” Source location Daniel LYLE · Prevention of Future Deaths report
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 focus in police officer training on practical strategies for decision making in mental health situations
Wider context from the report “(1) Whilst recognising that police officers cannot be doctors or nurses nor should they be, it is a concern that training for officers whether initial or refresher is not sufficiently focused on:
(a) an understanding of the symptoms and presentation of mental health conditions;
(b) possible practical strategies informed by mental health professionals and those suffering such conditions as will enable officers to optimise their decision making under the national decision making model.
” Source location Daniel LYLE · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.