19 May 2026 Catherine Mary MORGAN · Prevention of Future Deaths report Kent and Medway
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Concerns raised 2
Failure to include a patient photograph in the grab pack View source Lack of a voluntary-patient checklist for measures taken to locate the patient View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Catherine Mary MORGAN · 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
Catherine Mary Morgan, who was receiving mental health care, left hospital on unescorted leave and was later located near Dover Castle. She jumped to her death at 20.16 on 4 September 2024. Concerns included delays in the police response to reports that she was missing, and inadequate systems for assessing, authorising, communicating and monitoring voluntary patients’ leave.
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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 Failure to include a patient photograph in the grab pack
Wider context from the report “5. A photograph of the patient was not included in the grab pack . Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” Source location Catherine Mary MORGAN · 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 Lack of a voluntary-patient checklist for measures taken to locate the patient
Wider context from the report “5. A photograph of the patient was not included in the grab pack. Unlike detained patients there
was no checklist for voluntary patients as to the measures taken to locate the patient
” Source location Catherine Mary MORGAN · Prevention of Future Deaths report
Open source 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 Review and update the leave, informal-patient leave, and absent-or-missing-person policies to align practice, NICE guidance and legal requirements, including photographs and voluntary-patient checklists.
Verbatim wording from the response “The Trust continues to evaluate its transition towards a personalised approach to risk assessment and suicide prevention. In respect of the Inquest process, it was identified there is still some work to be done with respect to aligning all other policies with the transformed Clinical Risk Assessment and Management of Harm policy. In particular, there are aspects within the AWOL, Absent and Missing Persons policy which retain “old” low/medium/high classifications, i.e. the checklist used to guide decision making where a patient is identified as AWOL. This policy has now been marked as under review as was previously indicated in the Trust’s evidence in this case.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
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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 Mental Health Code guidance requiring patient photographs in grab packs applies to detained patients, not voluntary patients.
Verbatim wording from the response “The requirement in the Trust's AWOL policy for there to be a current photograph associated with a patient's grab pack derives from the Mental Health Code of Practice’s guidance that detained patients should have a photograph included in their notes (27.22). The Trust acknowledges that its policy does not make clear that this guidance relates to detained patients rather than voluntary patients.” Source location Response from South London and Maudsley NHS Foundation Trust
Open published response
Concerns raised 1
Failure to communicate critical missing-person welfare information to relevant officers View source
This report raised 1 other concern. 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
Durham Constabulary
Implement a process for directly recording and sharing new or updated missing-person information with investigating officers and reviewing supervisors.
View source
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AI-generated summary
Natalie Louise AINSWORTH · 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
Natalie Louise Ainsworth, aged 29, was found deceased on 13 February 2025 at an address in Stanley, County Durham. Police were informed that she had earlier threatened to take her own life, but this information was not known to key officers and was not included in the subsequent risk assessment or response. The report also identified that the risk assessment failed to properly consider known or expected information about her vulnerability and history of mental health issues, self-harm and substance abuse.
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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 Failure to communicate critical missing-person welfare information to relevant officers
Wider context from the report “Natalie was a vulnerable missing person considered to be at medium risk. A call was made to Police on the 13th February 2025 at 15:01 hours expressing concern for Natalie's welfare and informing Police of a new address where she may be and informing Police that she had earlier threatened to take her own life. Although the control room recorded that information was passed on to the relevant officer, neither the Inspector who undertook an updated a risk assessment some two hours later, nor the Officer making enquiries, was aware that Natalie had threatened to take her own life.
This important information was therefore not part of the risk assessment and not factored into subsequent Police actions , including in terms of whether to force entry to the property which was visited by the Police.
Further the risk assessment carried out at 1704 hours was not a robust assessment of the risks which were known, or ought to have been known, by Police at that time.
In particular the risk assessment fails to consider Natalie's vulnerability as a person with a history of mental health issues, self harm and substance abuse, records incorrectly that there is no indication that the person is likely to take their own life, records incorrectly that the person has no mental health issues, and records incorrectly that the person has not been involved in a violent incident prior to them disappearing.
An accurate and robust assessment of risk is essential to ensure that the nature and extent of any Police response is proportionate, and resources deployed appropriately, particularly when welfare/safety concerns are raised, as they were in Natalie's case.
” Source location Natalie Louise AINSWORTH · Prevention of Future Deaths report
Open source 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 Implement a process for directly recording and sharing new or updated missing-person information with investigating officers and reviewing supervisors.
Verbatim wording from the response “Since the issuing of the notice the Force have reviewed processes around the recording of additional information received into the Force Control Room as part of a missing person investigation.” Source location Response from Durham Constabulary
Open published response
Concerns raised 2
Failure to use understandable terminology when questioning members of the public reporting missing persons View source Lack of police staff understanding of the meaning of ‘suicidal ideation’ when responding to missing-person reports View source
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
Devon & Cornwall Police
Continue delivering Control Room refresher training on suicidality, fluctuating risk, plain language and broader exploratory questioning.
View source
Devon & Cornwall Police
Clarify in operational guidance that “suicidal ideation” means thoughts or feelings about suicide.
View source
Devon & Cornwall Police
Introduce operational guides for frontline officers and staff addressing Article 2 risks and suicidality.
View source
Devon & Cornwall Police
Issue and deliver reinforced training and operational guidance on the broad spectrum of risk associated with suicidality throughout 2026.
View source See 1 more action
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AI-generated summary
David John Thompson · 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
David John Thompson went missing from his home on 6 March 2023 after experiencing low mood, previous thoughts of suicide and challenging life events, and was located the following morning. The report raises concerns that police use and understanding of the term “suicidal ideation” led to relevant risk information not being recorded and may have prevented the risk posed by a missing person from being fully appreciated.
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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 Failure to use understandable terminology when questioning members of the public reporting missing persons
Wider context from the report “(1) The inquest heard that when Mr. Thompson’s partner reported him missing to the police, she was repeatedly asked (by both the 999 call handler and the attending police officers) whether he had demonstrated any ‘suicidal ideation’. It was clear that she did not fully understand what that meant, and as a result information which would have been relevant to the consideration of the level of risk presented by Mr. Thompson going missing was not recorded by the police.
(2) Furthermore, I heard evidence that the term ‘suicidal ideation’ was still being widely used by the constabulary when asking questions of members of the public who were reporting missing persons , and I am concerned that a member of the public may not understand what is being asked of them and may not therefore respond appropriately .
” Source location David John Thompson · 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 Lack of police staff understanding of the meaning of ‘suicidal ideation’ when responding to missing-person reports
Wider context from the report “(3) During the course of the inquest I heard evidence from 5 police officers and 2 members of the police staff. When asked what their understanding of the term ‘suicidal ideation’ was, their answers were vague and inconsistent . There therefore appears to be a lack of understanding by those employed by the police as to what the term means , creating a danger that the risk posed by a missing person is not fully appreciated by staff responding to a missing person report .
” Source location David John Thompson · Prevention of Future Deaths report
Open source 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 Continue delivering Control Room refresher training on suicidality, fluctuating risk, plain language and broader exploratory questioning.
Verbatim wording from the response “As a Force, we will continue to deliver refresher training to Control Room Staff to further strengthen their understanding of suicidality, associated risks, and the dynamic and fluctuating nature of such incidents.” Source location 2026-0080 - Response from Devon and Cornwall Police
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 Clarify in operational guidance that “suicidal ideation” means thoughts or feelings about suicide.
Verbatim wording from the response “Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.” Source location 2026-0080 - Response from Devon and Cornwall Police
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 Introduce operational guides for frontline officers and staff addressing Article 2 risks and suicidality.
Verbatim wording from the response “3. Reinforcement of the above approach to frontline officers and staff through the introduction of operational guidance (Op Guides) relating to incidents involving Article 2 risks and suicidality.” Source location 2026-0080 - Response from Devon and Cornwall Police
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 Issue and deliver reinforced training and operational guidance on the broad spectrum of risk associated with suicidality throughout 2026.
Verbatim wording from the response “Guidance issued in 2024 clarified that the term ‘suicidal ideation’ refers to thoughts of suicide (with reference to publications within the Lancet, and commentary provided in open-source by the Samaritans within which ‘ideation’ relates primarily to ‘thinking about suicide or could be making a plan to take their own life. This can range from a passing thought to a detailed plan’). This clarification has been further reinforced and incorporated into training and operational guidance that is being issued and delivered throughout 2026 – with specific emphasis on the wide variety of incidents and risks that the term encompasses.” Source location 2026-0080 - Response from Devon and Cornwall Police
Open published response
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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 Rigid definitions and scripted questions are not adopted because they may create false reassurance and information loss; plain language and open questioning are preferred.
Verbatim wording from the response “Whilst ‘suicidal ideation’ may be considered a clinical term in some contexts, the Force recognises that in emergency situations and when communicating with members of the public, it is often more appropriate to use plain language that is not prescribed or confined to a single definition. Accordingly, operational practice encourages the use of straightforward terminology such as ‘thoughts or feelings about suicide’ when discussing potential suicide risk.” Source location 2026-0080 - Response from Devon and Cornwall Police
Open published response
6 Feb 2026 Mansoor Zaman · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Delays in reporting an absconded patient as missing to the police View source
This report raised 10 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. 2
The Trust
Deliver refresher training to ward staff on applying the Trust and Pan-London AWOL policies together in practice.
View source
The Trust
Develop and implement mandatory AWOL policy training for all clinical staff, including competency assessment against both applicable AWOL policies.
View source
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AI-generated summary
Mansoor Zaman · 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
Mansoor Zaman, a 27-year-old man with a history of suicidality, substance misuse and EUPD, absconded from a mental health ward on 8 December 2024 after displaying suicidal intent and erratic and aggressive behaviour. His body was recovered on 29 December 2024. The substantive concerns included failures to use available mental health authorisations, reassess risk and observation levels, adequately document care, and promptly report him missing to police; the inquest jury identified some of these failures as factors that probably or possibly contributed to his death.
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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 Delays in reporting an absconded patient as missing to the police
Wider context from the report “6. The dilatory response of staff on the ward to report Mr Zaman as a missing person to the police , an action that did not happen for almost three hours after it was known that he had absconded .
” Source location Mansoor Zaman · Prevention of Future Deaths report
Open source 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 Deliver refresher training to ward staff on applying the Trust and Pan-London AWOL policies together in practice.
Verbatim wording from the response “29. You heard at the inquest that the Trust’s AWOL policy has been refined and makes it clear when 999 should be called. Additionally, within the next two months, the ward staff will undergo refresher training on both policies and understand how they apply together in practice, so that AWOL procedures are followed consistently and safely.” Source location 2026-0072 - Response from East London NHS Foundation Trust
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 Develop and implement mandatory AWOL policy training for all clinical staff, including competency assessment against both applicable AWOL policies.
Verbatim wording from the response “30. The senior clinical team will also develop and implement mandatory AWOL policy training for all clinical staff, including a competency assessment covering both the Trust AWOL Policy and the Pan-London Joint AWOL Policy.” Source location 2026-0072 - Response from East London NHS Foundation Trust
Open published response
9 Dec 2025 Katherine Wright, known as Sarah · Prevention of Future Deaths report Oxfordshire
View report summary
Concerns raised 1
Lack of training and operational guidance for adequate premises searches in missing person cases View source
This report raised 1 other concern. 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. 3
Thames Valley Police
Update Missing Persons Operational Guidance with structured premises-search procedures, hazard controls, equipment guidance, and supervisory escalation requirements.
View source
Thames Valley Police
Integrate the new premises-search guidance into Foundation Training for new recruits.
View source
Thames Valley Police
Communicate the premises-search guidance changes to all officers through a force-wide communication.
View source
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AI-generated summary
Katherine Wright, known as Sarah · 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
Katherine Wright, known as Sarah, was reported missing on 15 December 2023 and was found deceased in her flat on 20 December 2023 after an initial police search did not locate her. The report identified concerns about inadequate guidance and training for searches in missing-person cases, and the lack of protocols for escalating safety concerns that may prevent an adequate search.
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 training and operational guidance for adequate premises searches in missing person cases
Wider context from the report “1. Lack of training and guidance for frontline officers on conducting searches of premises in missing person cases.
Evidence given by the Police at the Inquest indicated that there is no structured training or clear operational guidance on what constitutes an adequate search , including checking all areas of a property where a person could reasonably be found .
” Source location Katherine Wright, known as Sarah · Prevention of Future Deaths report
Open source 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 Update Missing Persons Operational Guidance with structured premises-search procedures, hazard controls, equipment guidance, and supervisory escalation requirements.
Verbatim wording from the response “To address this, we have reviewed our Missing Persons Operational Guidance and included a new section dedicated to the searching of premises for missing persons. This includes sub sections on the extent of the search; equipment and resources that may be used including the use of personal protective equipment; potential hazards and how the Specialist Search Unit may be used to advise and mitigate such hazards. The source documents used to create this section include a College of Policing e-learning package ‘Searching Premises’ and an input for all new recruits on Specialist Police Search Advisors. This new guidance has been shared with our Learning and Development department and will be integrated into Foundation Training for new recruits. It has also been shared with all officers in a force wide communication.” Source location Response from Thames Valley Police
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 Integrate the new premises-search guidance into Foundation Training for new recruits.
Verbatim wording from the response “To address this, we have reviewed our Missing Persons Operational Guidance and included a new section dedicated to the searching of premises for missing persons. This includes sub sections on the extent of the search; equipment and resources that may be used including the use of personal protective equipment; potential hazards and how the Specialist Search Unit may be used to advise and mitigate such hazards. The source documents used to create this section include a College of Policing e-learning package ‘Searching Premises’ and an input for all new recruits on Specialist Police Search Advisors. This new guidance has been shared with our Learning and Development department and will be integrated into Foundation Training for new recruits. It has also been shared with all officers in a force wide communication.” Source location Response from Thames Valley Police
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 Communicate the premises-search guidance changes to all officers through a force-wide communication.
Verbatim wording from the response “To address this, we have reviewed our Missing Persons Operational Guidance and included a new section dedicated to the searching of premises for missing persons. This includes sub sections on the extent of the search; equipment and resources that may be used including the use of personal protective equipment; potential hazards and how the Specialist Search Unit may be used to advise and mitigate such hazards. The source documents used to create this section include a College of Policing e-learning package ‘Searching Premises’ and an input for all new recruits on Specialist Police Search Advisors. This new guidance has been shared with our Learning and Development department and will be integrated into Foundation Training for new recruits. It has also been shared with all officers in a force wide communication.” Source location Response from Thames Valley Police
Open published response
1 Dec 2025 Lewis Bates · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to correctly distinguish between missing-person reporting and the Right Person Right Care initiative 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
Lewis Bates · 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
Lewis Bates was reported missing after leaving his mother and stepfather’s house, having previously expressed an intention to end his life if he could not see his children. His body was found approximately two hours and 21 minutes after the missing-persons report. Concerns included the absence of guidance for call handlers about reasonable enquiries, advice to contact healthcare providers, and apparent confusion about the applicable police response process.
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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 Failure to correctly distinguish between missing-person reporting and the Right Person Right Care initiative
Wider context from the report “3. Having considered the audio recording and transcript of the 999 call with the utmost care, I am concerned that the call handler appears confused as to whether she was dealing with the call as a missing persons report or under the Right Person Right Care initiative . I am concerned such confusion was a relevant factor in the appropriate police response to the 999 call not being provided on this occasion.
” Source location Lewis Bates · Prevention of Future Deaths report
Open source 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 Review Missing Person and RCRP policies, consult stakeholders, and progress senior-officer sign-off to clarify their distinction and reduce operational confusion.
Verbatim wording from the response “GMP will conduct a full review of both the Missing Person and RCRP policies to identify areas of overlap and potential confusion. Following this review and wherever appropriate:” Source location Response from Greater Manchester Police
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 Deliver enhanced call-handler and supervisor training on vulnerability assessment, complex cases, escalation decisions, and supervisory quality assurance.
Verbatim wording from the response “Rather than imposing rigid lists, GMP will strengthen decision-making through enhanced training and guidance for call handlers. This will include:” Source location Response from Greater Manchester Police
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 Update the FCCO Sherlock guidance system with revised instructions for distinguishing Missing Person and RCRP procedures.
Verbatim wording from the response “Alongside the re-publication of amended policies, the Public Protection Division will work closely with the Force Contact, Crime and Operations (FCCO) Branch to ensure that revised guidance is made available to all call handlers and their supervisors. This will be delivered to respective teams and police staff via additional training. This measure is designed to prevent any further confusion and ensure consistency in decision-making.” Source location Response from Greater Manchester Police
Open published response
19 Oct 2025 Alexander Philip MCCORMACK · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 1
Failure of the case-importing process to provide reliable guidance during competing high-risk priorities View source
This report raised 2 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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AI-generated summary
Alexander Philip MCCORMACK · 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
Alexander Philip McCormack was found deceased in a tent at Fermyn Woods Country Park on 27 February 2023 after expressing suicidal thoughts and plans and contacting mental health services with an intention to end his life. The inquest concluded that his death was suicide. Concerns were raised that delays in transferring missing-persons information between police forces could affect risk assessment and the formulation of lines of inquiry, particularly where officers lacked training in importing cases onto the COMPACT system.
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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 the case-importing process to provide reliable guidance during competing high-risk priorities
Wider context from the report “The court heard evidence that whilst new recruits to the force, and those promoted internally, are trained on COMPACT and importing cases, this is not covered on the induction training for transferees from other forces at a particular rank. Guidance on how to transfer / import cases is available on the force intranet but this would need to be accessed and followed by the relevant officer at the time of importing the information ; essentially leaning through experience. This gives rise to a concern as it could be during a busy night shift where a Reactive Inspector has competing high risk priorities .
” Source location Alexander Philip MCCORMACK · Prevention of Future Deaths report
Open source report
14 Sep 2025 Charlotte Tetley · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 1
Failure to deploy police resources for high-risk missing persons unless they have expressed an intention to end life View source
This report raised 1 other concern. 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. 7
Cheshire Constabulary
Implement RCRP decision-support toolkits, standard questions, digital recording and escalation scripts for concern-for-safety calls.
View source
Cheshire Constabulary
Deliver RCRP legal, procedural and toolkit training to FCC staff, supervisors, incident managers and wider force personnel.
View source
Cheshire Constabulary
Provide RCRP training materials and communications to partner agencies to support their education, awareness and use of the escalation process.
View source
Cheshire Constabulary
Establish supervisor and Force Incident Manager reviews, including override and partner-requested mutual-aid escalation routes for disputed or uncertain deployment decisions.
View source
Cheshire Constabulary
Operate live quality assurance of concern-for-safety incidents, with feedback, supervisory learning and further development sessions where required.
View source
Cheshire Constabulary
Deploy trained RCRP floorwalkers and subject-matter experts to support call handlers during implementation and operational use.
View source
Cheshire Constabulary
Revise the Missing From Home policy to align with RCRP and require consideration of known location, reasonable enquiries and expressed concerns.
View source See 4 more actions
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AI-generated summary
Charlotte Tetley · 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
Charlotte Tetley died on 24 September 2024 after deliberately sitting on railway tracks and being struck by a train. The report describes concerns about the police and ambulance response after she left hospital on 18 September 2024 despite reported suicidal feelings and professional concerns about her immediate safety. It also identifies concerns about the application of missing-person response policy when the person’s whereabouts are unknown.
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 deploy police resources for high-risk missing persons unless they have expressed an intention to end life
Wider context from the report “That despite Ms Tetley being found on train tracks on the 18 September 2024, and reporting to workers who found her that she felt suicidal, the police would respond when she absconded from the Accident and Emergency Department the same day. When the Clinical Lead of Psychiatry Liaison escalated the matter and expressed concern of an immediate risk for safety given her extensive medical history, and her lack of engagement in the department that day, she was informed that as Ms Tetley had not expressed an intention to end her life before leaving the department, it could not be known that it was her intention to end life. The police informed the Clinical Lead to contact the ambulance response vehicle. When she did this, they declined to respond as they were unaware of Ms Tetley’s whereabouts.
I am concerned that if a very narrow interpretation of policy is applied by the police when professionals report a concern for a high risk missing person in circumstances where they consider there to be an immediate risk to life , there will be a risk of future deaths occurring. If the policy is interpreted such that police resources will only be deployed if the missing person has expressed an intention to end life as they leave the hospital , there is a risk that future deaths will occur. It is unlikely that the ambulance response vehicle will be deployed if the whereabouts of the missing person is unknown, which will result in the missing person not being able to receive medical attention until their whereabouts are known. By the time that they are located, there is a risk that they will no longer be alive.
” Source location Charlotte Tetley · Prevention of Future Deaths report
Open source 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 Implement RCRP decision-support toolkits, standard questions, digital recording and escalation scripts for concern-for-safety calls.
Verbatim wording from the response “• Phase 1 launched on 8th January 2024 and focussed on ‘Concern for Safety’. This introduced a toolkit regarding general concern for welfare calls that Cheshire Police receive from the public and partners.” Source location Response from Cheshire Constabulary
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 Deliver RCRP legal, procedural and toolkit training to FCC staff, supervisors, incident managers and wider force personnel.
Verbatim wording from the response “This is supported by a policy document that explains the legal and statutory obligations, as well as the context and considerations that underpin Right Care Right Person implementation in Cheshire. Every member of staff in the FCC received detailed training in the law, the process and the application of RCRP prior to implementation. This included all Force Incident Sergeants (“FIS”), Force Incident Managers (“FIM”), FCC Supervisors and the Senior leadership team. Wider engagement and training was rolled out within the force to all departments. The training and supporting documents have also been shared with partner agencies to assist their own training and approach to RCRP (RCRP Legal and Escalation slides attached as Appendix Four).” Source location Response from Cheshire Constabulary
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 Provide RCRP training materials and communications to partner agencies to support their education, awareness and use of the escalation process.
Verbatim wording from the response “This is supported by a policy document that explains the legal and statutory obligations, as well as the context and considerations that underpin Right Care Right Person implementation in Cheshire. Every member of staff in the FCC received detailed training in the law, the process and the application of RCRP prior to implementation. This included all Force Incident Sergeants (“FIS”), Force Incident Managers (“FIM”), FCC Supervisors and the Senior leadership team. Wider engagement and training was rolled out within the force to all departments. The training and supporting documents have also been shared with partner agencies to assist their own training and approach to RCRP (RCRP Legal and Escalation slides attached as Appendix Four).” Source location Response from Cheshire Constabulary
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 Establish supervisor and Force Incident Manager reviews, including override and partner-requested mutual-aid escalation routes for disputed or uncertain deployment decisions.
Verbatim wording from the response “3. Caller insists on deployment (after no deployment decision reached) and the matter thus requires escalation to a Supervisor for review.” Source location Response from Cheshire Constabulary
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 Operate live quality assurance of concern-for-safety incidents, with feedback, supervisory learning and further development sessions where required.
Verbatim wording from the response “Quality assurance is undertaken by the RCRP project and implementation team conducting live QA of incidents as they occur to ensure consistent application of RCRP in line with training. Direct feedback is given” Source location Response from Cheshire Constabulary
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 Deploy trained RCRP floorwalkers and subject-matter experts to support call handlers during implementation and operational use.
Verbatim wording from the response “During go live and throughout 2024 RCRP floorwalkers were employed to support staff in making decisions and answering questions. This was via experienced staff who received additional training and were selected for their knowledge of law and procedure and their ability to consistently apply RCRP to reported incidents. This was complemented by the FCC Supervisors on duty, and the RCRP project team who worked alongside staff in FCC Calls room. The training is as follows:” Source location Response from Cheshire Constabulary
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 Revise the Missing From Home policy to align with RCRP and require consideration of known location, reasonable enquiries and expressed concerns.
Verbatim wording from the response “Cheshire Police revised the Missing From Home (MFH) policy to ensure it was aligned with the introduction of Right Care Right Person. This sets three aspects for consideration if someone is missing. These three considerations were included in part of the training all FCC staff received prior to the introduction of RCRP. They are:-” Source location Response from Cheshire Constabulary
Open published response
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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 Police deployment is not limited to cases involving an expressed intention to end life; deployment occurs where a real and immediate risk is identified.
Verbatim wording from the response “To reassure, it is not the case that police will only deploy if an expression to end life is made on leaving the hospital. In the case referred to, there was no such expression at all on the evidence available but in general terms, the assessment is detailed but there must be real and immediate risk to life or a serious risk of harm (ie present, continuing and happening now).” Source location Response from Cheshire Constabulary
Open published response
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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 RCRP training, toolkits, procedures and escalation processes provide a sufficient framework for consistent risk assessment and police deployment decisions.
Verbatim wording from the response “Whilst the RCRP process involves individual decision making, the toolkits and procedures ensure consistency and sound decision making to avoid differing interpretations of policy.” Source location Response from Cheshire Constabulary
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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 Hospital procedures for patients leaving healthcare settings provide sufficient arrangements for making enquiries and resolving concerns before requesting police assistance.
Verbatim wording from the response “In this case, the RCRP policy was correctly applied and appropriate advice given. The hospital have clear processes and procedures in place when patients simply walk out of hospital. Having made further enquiries, the hospital called back to confirm the matter was resolved.” Source location Response from Cheshire Constabulary
Open published response
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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 Hospitals should undertake reasonable enquiries and use their available avenues to establish a missing patient's whereabouts before requesting police assistance.
Verbatim wording from the response “In this case, there were enquiries the hospital could and should undertake. Indeed, the Royal College of Emergency Departments publication “The Patient who Absconds” (2020) process makes that clear. In the case of incidents of this type, we would reasonably expect that the professionals calling would have made suitable checks with relevant teams and gathered information before contacting police. They would also utilise appropriate avenues at their disposal.” Source location Response from Cheshire Constabulary
Open published response
23 May 2025 George Kenneth Fraser · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to determine whether the missing person procedure should be activated View source
This report raised 5 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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AI-generated summary
George Kenneth Fraser · 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
George Kenneth Fraser, aged 37, was found deceased at his home after mental health services had been unable to contact him and his family had last contacted him several weeks earlier. The cause and date of death were uncertain. Concerns included the absence of a clear care plan and robust risk assessment, and inadequate action and communication following failed contact and concerns raised by a friend and family.
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 determine whether the missing person procedure should be activated
Wider context from the report “(3) The Mental Health and Wellness Team had been unable to reach Mr Fraser from the 16 July 2024. On the 18 July 2024 a friend contacted the mental health team to raise concern about his lack of contact with Mr Fraser. No action was taken at this time to review the risk of harm to Mr Fraser or to determine whether the Trust’s missing person procedure should be activated . There was no meaningful contact with the family to report the concerning lack of contact with Mr Fraser, until the 29 July 2024.
” Source location George Kenneth Fraser · Prevention of Future Deaths report
Open source report
20 Feb 2025 Duncan HOLLOWAY · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to teach police contact in psychotherapy planning for missing or suicidal clients View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Duncan HOLLOWAY · 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
Duncan Holloway died after jumping from a bridge at approximately 5am on 18 July 2024, being killed by the impact with the railway tracks below. The concerns included psychotherapy note-keeping, training and response to suicidality, whether psychotherapists unable to manage suicidality should practise with at-risk clients, and a lack of joined-up care between agencies.
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 teach police contact in psychotherapy planning for missing or suicidal clients
Wider context from the report “3. When Mr Holloway’s friend contacted the psychotherapist to say that he was missing, knowing that he had neither attended nor cancelled their last consultation the psychotherapist was very concerned for his safety. She instructed the friend to go round to his home, but it did not occur to her to call the police.
The friend did this, but can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning ?
” Source location Duncan HOLLOWAY · Prevention of Future Deaths report
Open source 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 Require accredited-course students to learn when confidentiality may be breached, including referral to emergency services where necessary.
Verbatim wording from the response “According to the BACP Accreditation of Training Courses, all students enrolled in BACP-accredited courses must be trained in making informed decisions about breaching confidentiality when necessary. This includes understanding when it is appropriate to refer clients, particularly in situations requiring emergency intervention.” Source location Response from BACP
Open published response
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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 Accredited courses teach emergency referrals and confidentiality decisions, but would not teach police contact solely on a third party’s assessment.
Verbatim wording from the response “3. ...can it be right that contacting the police in such a situation is not taught as part of psychotherapy planning.” Source location Response from BACP
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.