Recurring concern

Unreliable missing-person response

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First reported 21 Aug 2013•Latest report 19 May 2026

Definition

What this concern includes

Includes failures of controls dedicated to the missing-person response, such as staff understanding of the procedure, risk classification, communication of status, searches, escalation, agency coordination and family notification.

Not included

  • Excludes generic delays in escalation or communication that are not explicitly connected to a missing-person response.
  • Excludes unrelated patient-deterioration, emergency-response or clinical-escalation failures.
  • Excludes general accessibility or communication deficiencies concerning visits, relatives or care unless they concern notification or coordination within a missing-person response.
Reports
45

Distinct published reports

Individual concerns
75

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
112

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Metropolitan Police Service8
College of Policing7
Greater Manchester Police5
Department of Health and Social Care4
Surrey and Borders Partnership NHS Foundation Trust4
West Midlands Police4
East London NHS Foundation Trust3
Home Office3
National Police Chiefs’ Council3
Sussex Partnership NHS Foundation Trust3
Birmingham and Solihull Mental Health NHS Foundation Trust2
NHS England2
North London NHS Foundation Trust2
Sussex Police2
Association Of British Neurologists1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Michael James Crane · 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 James Crane lived in supported accommodation and was absent from the Home from 15 January 2024. He attended hospital and later a police station, but left without being reported missing; his body was retrieved from the River Thames on 18 January 2024. The inquest concluded that he drowned, contributed to by no missing person report being made to the police. The report raised concerns about the absence of MPS guidance for frontline officers dealing with people who may be missing but have not yet been reported as such.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of clear staff procedures after a resident is found by police

    Wider context from the report

    “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following: • staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours; • staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London; • staff advised the police in London that they intended to report the resident missing but then did not proceed to do so; • details about any additional training or steps taken to reduce the risks were very vague; and • details of specific policies and procedures in place at the time were vague. 2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident. ”

    Source location

    Michael James Crane · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to report an unexpectedly absent resident missing

    Wider context from the report

    “1) The registered manager of Island Place Residential Home gave evidence to the inquest, and her evidence revealed the following: • staff at the Home did not follow the Home’s own policy to report a resident missing once they have been unexpectedly absent for 24 hours; • staff seemed vague and confused about what, if anything, they should do once they became aware that the resident had been found by the police in London; • staff advised the police in London that they intended to report the resident missing but then did not proceed to do so; • details about any additional training or steps taken to reduce the risks were very vague; and • details of specific policies and procedures in place at the time were vague. 2) There was clear evidence from MPS officers that had the resident been reported missing, they could have done more to protect and safeguard the resident. ”

    Source location

    Michael James Crane · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of MPS guidance to frontline officers on people likely to be missing but not yet reported missing

    Wider context from the report

    “1) The MPS constable who gave evidence at the inquest, told me that: • if Mr Crane had been reported missing at the time he was in Charing Cross police station then there would have been more that officers could have done to keep him safe; • the fact that officers had heard (directly from staff) that the Home intended to report Mr Crane missing within the next 30 minutes, did not mean that there was more that the officers could have done at the time; and • there was not, either at that time or to date, any MPS guidance to frontline officers in relation to how to approach their powers under section 136 of the Mental Health Act or in relation to people who are likely to be missing but have not yet been reported as such. ”

    Source location

    Michael James Crane · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the missing-person policy and wider policies and procedures to clarify when residents should be reported missing.

    Verbatim wording from the response

    “There are a full set of policies and procedures available to all staff, which have since undergone a full review.”

    Source location

    Response from Prime Life
    Page 3 · response
    Published 1 November 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide additional training to Island Place staff and managers on when and how quickly residents should be reported missing.

    Verbatim wording from the response

    “As a provider we are committed to learning lessons from incidents such as the tragic one with Michael, since this incident we have reviewed our missing person policy and have provided additional training to the staff and management at Island Place in order to ensure that they have clear guidance on when and understanding on how quickly a person should be reported missing.”

    Source location

    Response from Prime Life
    Page 3 · response
    Published 1 November 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    No staff action was considered necessary after London police contact because the resident had capacity and was entitled to travel and leave the service.

    Verbatim wording from the response

    “There is a clear policy regarding what to do once they become aware of a missing resident, Michael had full capacity to travel wherever he wanted and therefore there was no action for the staff to take when they had contact from the police in London.”

    Source location

    Response from Prime Life
    Page 2 · response
    Published 1 November 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Even if reported missing, officers lacked further legal powers because he was an adult and section 136 criteria were unmet.

    Verbatim wording from the response

    “Even in the event that Mr Crane had been reported missing, the officers options were extremely limited. They had already formed the view that he did not meet the criteria for s136 MHA to be used and as Mr Crane was an adult, there were no other policing powers available to them. The care home were informed where Mr Crane was and provided no further details to the officers as to any risk Mr Crane may have posed to himself/others or any further details about his mental health that could have raised the risk to him.”

    Source location

    Response from Metropolitan Police Service
    Page 4 · response
    Published 1 November 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The resident was not considered missing while his whereabouts were known through hospital and police contacts, so reporting was not considered necessary earlier.

    Verbatim wording from the response

    “At this point MC had been off unit 13.5 hours and was not reported missing because he was not missing, we knew he was at St Thomas’s hospital in London and therefore did not need to report him as a missing person. 16th January 11:55- MC was escorted by a member of the hospital staff for a cigarette however he left the hospital and was seen boarding a bus bound for Victoria station. 16th January 12:00- St Thomas hospital called Island Place and said MC had absconded from the hospital. 16th January 16:00- Senior at Island Place called St Thomas hospital to see if he had returned and he had not. 16th January 17:30- PC Cante from town croft police called to say they had approached MC in the street to a welfare check on him and they asked if he was under any section, police said MC expressed he wasn’t ready to return to Island Place and they didn’t have any hold over him.”

    Source location

    Response from Prime Life
    Page 1 · response
    Published 1 November 2024

    Open published response
  2. Birmingham and Solihull

    AI-generated summary

    Tcherno Bari · 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

    Tcherno Bari, who had been detained under the Mental Health Act and admitted to a psychiatric unit with psychotic depression, left the hospital grounds while assessed as at high risk of suicide. He was found deceased the following day, 26 September 2023, hanging from a tree in parkland outside the police search area. The principal concerns were significant gaps in multi-agency coordination, communication of risk information, use of risk-assessment procedures, and the handling of differing assessments between mental health staff and police.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide attending police officers with the written risk rating

    Wider context from the report

    “(1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in-Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’. ”

    Source location

    Tcherno Bari · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to maintain an accurate and up-to-date missing person policy

    Wider context from the report

    “(5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP. I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date. ”

    Source location

    Tcherno Bari · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Replace Appendix C with a decision-recording form documenting the reasons for critical concern and provide it to attending police officers.

    Verbatim wording from the response

    “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Establish a process for officers to request electronic risk assessments through a central Locate Team inbox with overnight supervisory monitoring.

    Verbatim wording from the response

    “WMP recognise the importance that the BSMHFT risk assessment is shared with officers (referred to as ‘Appendix C’ in the PFD report) and that attending constables know to request this. Whilst officers will be reminded, within the policy update, to request a copy of the risk assessment and to take possession of it they will also be given an email address to provide to BSMHFT. BSMHFT will be asked to provide the risk assessment (Appendix C) electronically to this email address. The risk assessment will be received into the central Locate Team inbox ensuring a hard copy document is not misplaced and enabling timely supervisory review, if required. The Locate Team inbox is only monitored until 10pm. Therefore, for overnight issues the Duty Sergeant will be asked to monitor the inbox and to escalate any issues through supervision where appropriate.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update and approve the missing persons policy to incorporate RCRP, national guidance, partnership requirements and inquest feedback.

    Verbatim wording from the response

    “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Assign accountability for the missing persons policy to the new Executive Director of Quality and Safety/Chief Nursing Officer.

    Verbatim wording from the response

    “At the time of the inquest the Missing Persons Policy was being updated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why is the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend.”

    Source location

    Response from BSMHFT
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Continue updating and circulating the escalation process when contact details change.

    Verbatim wording from the response

    “The updated policy sets out clearly the RCRP escalation process (challenge process) under Appendix K. This has been circulated to responsible clinicians and senior nurses within BSMHFT. As the escalation procedure contact details alter in the future, the process will continue to be updated and circulated to all senior clinicians in BSMHFT and will continue to be part of the missing persons policy.”

    Source location

    Response from BSMHFT
    Page 2 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish the National Partnership Agreement setting principles and guidance for applying Right Care Right Person at the policing–mental health interface.

    Verbatim wording from the response

    “It may help if I outline the rationale and purpose of the National Partnership Agreement (NPA), as the Home Office was one of the signatories when it was published in July 2023.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and publish national Right Care Right Person guidance, toolkit and implementation materials for police forces and partner agencies.

    Verbatim wording from the response

    “It is also worthy of note that the first phase of the NPCC/College of Policing RCRP guidance was not published until July 2023 (alongside the NPA) which included the Senior responsible officer SRO role, Baseline and evaluation criteria and communication plan considerations modules. The policy considerations, force control room implementation and e-learning modules were published in December 2023. This was followed by the Implementation principles for incidents involving children in June 2024. It is our understanding that West Midlands Police are currently reviewing their policies and procedures against the Right Care Right Person national guidance.”

    Source location

    Response from NPCC
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.

    Verbatim wording from the response

    “Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.

    Verbatim wording from the response

    “As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter.”

    Source location

    Response from the Home Office
    Page 1 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.

    Verbatim wording from the response

    “healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate.”

    Source location

    Response from the Home Office
    Page 2 · response
    Published 6 June 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.

    Verbatim wording from the response

    “The Missing persons framework is another distinct policy area which falls outside of RCRP when it is established that a persons whereabouts cannot be ascertained and all reasonable enquiries have been made by the informant to ascertain their whereabouts.”

    Source location

    Response from NPCC
    Page 2 · response
    Published 6 June 2024

    Open published response
  3. South Yorkshire (Eastern)

    AI-generated summary

    Lee Bowman · 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

    Lee Bowman was last seen on 31 October 2021 after being reported as having injuries consistent with an assault, and his body was found on 3 January 2022. The medical cause of death was unascertained. The principal concerns were assumptions about his whereabouts and reasons for not contacting family, insufficient weight given to information from his family, and shortcomings in the police handling and risk assessment of the missing-person reports.

    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 assess missing-person vulnerability without relying on assumptions about addiction

    Wider context from the report

    “1. There were significant assumptions made about the whereabouts of Lee and the reasons for his failure to contact family. The assumptions were based on the facts of Lee's addiction which on one view ought to have been identified as a vulnerability, on another view were wholly irrelevant in the context of his family confirming he was in day contact until 31 October 2021. ”

    Source location

    Lee Bowman · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Update Missing Persons APP to warn against imprecise, value-laden terminology and require clear descriptions relevant to risk assessment.

    Verbatim wording from the response

    “In reading your report, our subject matter expert was troubled by the term ‘chaotic lifestyle’ that appeared to have been used in some of the risk assessments. Terminology such as this is imprecise and invites readers of such comments to assign their own assumptions to what the term means. We will update our Missing Persons APP to alert police officers and staff to the need to avoid such value laden but imprecise terms. Instead, they should set out clearly and simply what matters and issues have been identified that have a bearing on the assessment of risk.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 28 February 2024

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Publish Evidence Based Guidelines on vulnerability-related risk assessment, including gathering information from multiple sources to inform professional risk judgements.

    Verbatim wording from the response

    “Your second matter of concern refers to reliance on PNC and intelligence records. Unfortunately, the report to us contains no detail of what was in these records or any commentary on why investigators gave them greater weight. It is, therefore, difficult for us to respond to these particular circumstances. However, the College has recently published Evidence Based Guidelines on Risk Assessment Vulnerability-related risks | College of Policing. This document is based on a broad range of research and sets out clear guidance on how to carry out risk assessment and is based on risk principles Risk | College of Policing. It emphasises the importance of gathering information from a range of sources to inform a decision maker’s professional judgement about the level of risk and what action should be taken to address that risk.”

    Source location

    Response from College of Policing
    Page 2 · response
    Published 28 February 2024

    Open published response
  4. Inner North London

    AI-generated summary

    Heather FINDLAY · 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

    Heather Findlay was detained under section 2 of the Mental Health Act at Mile End Hospital and ran away while on escorted leave on 11 June 2020. She was later found by a member of the public in a nearby park; the inquest concluded that she died by suicide, with a medical cause of death of hypoxic ischaemic encephalopathy and ████████ toxicity. The principal concerns included staff preparedness and procedures when a detained patient absconds, unclear responsibilities between ELFT and the police, communication of suicide risk, and the adequacy of risk grading and organisational learning.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Confusion about police contact when a patient is missing

    Wider context from the report

    “6. ELFT staff all told me that, after Ms Findlay had run off, they still graded her as medium rather than high risk. She had had long term suicidal thoughts, had made previous attempts on her life and, prior to being admitted to hospital on 20 May 2020 had purchased ████████ and had planned to take this to kill herself. However, she had appeared to improve in hospital, and had been granted 15 minutes’ escorted leave twice a day since 1 June without incident. At one point in her evidence it appeared to me that the matron, taking the point that by running away Ms Findlay had acted in a manner that was wholly unexpected by the trust, was of the view that Ms Findlay should then have been re-categorised as high risk. However, following re-examination by counsel for ELFT the matron appeared to retract this and to return to her former position that, even after she had run away Ms Findlay was only of medium risk to herself. It is of course a matter of clinical opinion what risk grading a patient should be given, and no person can see into the future. However, • the jury found a failure by ELFT to recognise that, by 11 June 2020, Ms Findlay was at imminent risk of suicide by ████████; and • any investigation following a death like Heather Findlay’s presents an opportunity for sober and searching reflection. So I am concerned that an element of positional bias may have influenced the thinking of ELFT staff. I am concerned about this particularly because, when giving evidence at inquest, the ELFT serious incident investigation author was adamant that it was only appropriate for the HCA who called the police on 11 June 2020 after Ms Findlay had run away, to tell the police of a risk of self harm not of a risk of suicide. Her rationale for this was that the last time Ms Findlay had articulated a plan to kill herself, was when she was found in hospital with a ligature round her neck on 28 May 2020. This position seems lacking the necessary reflection. I draw your attention to earlier prevention of future deaths reports (PFDs) as follows: • Sent to ELFT on 8 June 2023 by Assistant Coroner Buckett following the inquest touching the death of Hilary (Billy) Guedalla, including concern regarding the failure of ELFT to inform the police of the serious suicide risk that the deceased posed to themselves; and the confusion among staff about who should be contacted and in what manner, once a patient was found to be missing. • Sent to ELFT on 25 January 2023 by me following the inquest touching the death of Andrew Largin, including concern about omissions from a serious incident investigation. • Sent to ELFT on 20 October 2021 by me following the inquest touching the death of Freeda Glausiusz, including concern about a lack of learning culture at ELFT. ”

    Source location

    Heather FINDLAY · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.

    Verbatim wording from the response

    “The Commissioner of the Metropolitan Police, ████████, wrote to Health and Social Care Partners on 24th May 2023, to set out the Met Police’s intention to implement the national Right Care, Right Person approach. Under Assistant Commissioner ████████ a team is now working to put this in place, and an initial senior board has taken place with senior health and social care providers to work towards RCRP implementation. This is also in parallel with the work being done by health care providers on the London mental health concordat. A key aspect of this is working with all of the”

    Source location

    Response from Metropolitan Police
    Page 5 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the Trust’s responses and related reports to determine whether further action is needed.

    Verbatim wording from the response

    “I do however take the concerns raised seriously, and I thank you for bringing them to my attention, together with the other Reports to Prevent Future Deaths you highlight concerning the care of other patients at the Trust. I have asked that NHS England is sighted on the Trust’s response to your Report, as well as the responses to the other cases and we will consider these carefully, to include whether any further action needs to be taken. I have already been sighted on the Trust’s Patient Safety Serious Incident Review Report on this matter and note that they have taken a learning to ensure that the police are provided with a direct dial number whenever reporting a patient absconding, which did not happen in this case.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise the Missing and AWOL Policy to clarify safe responses when patients abscond from escorted leave.

    Verbatim wording from the response

    “Although this was the practice in operation at the time, the Trust has taken action to review the relevant part of its Missing and Absent Without Leave (AWOL) Policy to reflect this practice. The updated version will read as below:”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational decisions about missing-person investigations are outside the Home Office’s authority.

    Verbatim wording from the response

    “With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Responsibility for operational missing-person decisions rests with individual police forces and their Chief Officers.

    Verbatim wording from the response

    “With regards to the response to the missing person report made by the East London Foundation Trust (ELFT) to the Metropolitan Police Service (MPS), the police investigation of a missing person report is an operational decision for individual police forces. The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, my officials have consulted the MPS to gain assurance that the correct protocols are in place in order to prevent future incidents of this nature.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The MPS Affinity Protocol is considered sufficient because it reflects the NPCC framework for missing persons from healthcare settings.

    Verbatim wording from the response

    “The MPS response will set out details of its Affinity Protocol, a joint agreement between the MPS and ELFT, which aligns with the NPCC’s framework, published in October 2020, and accessible at https://www.gov.uk/government/publications/the-multi-agency-response-for-adults-missing-from-health-and-care-settings-a-national-framework-for-england.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.

    Verbatim wording from the response

    “The concerns in your Report relate to organisational policy at East London Foundation Trust as well as policy within the Metropolitan Police Service. NHS England is not therefore the appropriate organisation to respond to many of the concerns raised.”

    Source location

    Response from NHS England
    Page 1 · response
    Published 22 June 2023

    Open published response
  5. Inner North London

    AI-generated summary

    Hilary Clare (Billy) Guedalla · 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

    Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

    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 make proper efforts to contact a missing patient's family

    Wider context from the report

    “9. No proper efforts were made to contact members of the deceased’s family once the deceased was found to be missing. ”

    Source location

    Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Delays in notifying police and ambulance services when a patient is missing

    Wider context from the report

    “7. Once the deceased was found to be missing from the unit, there was an unexplained delay in informing the police and ambulance service, a failure to inform either of the serious suicide risk which the deceased posed to themselves and a lack of appreciation of the urgency of the situation by staff generally. ”

    Source location

    Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to follow the missing-patient response policy and identify required contacts and methods

    Wider context from the report

    “8. The hospital policy which applied to missing patients was not properly adhered to by staff and there was confusion about who should be contacted and in what manner, once a patient was found to be missing. ”

    Source location

    Hilary Clare (Billy) Guedalla · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Add explicit family-contact instructions to the updated missing-patient policy and discuss them with Gardner Ward staff.

    Verbatim wording from the response

    “I can confirm that explicit information about contacting family members is provided in the updated policy and was discussed with Gardner Ward staff during its review of the policy.”

    Source location

    Response from East London NHS Foundation Trust
    Page 5 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Reinforce correct escalation processes for missing service users through the Gardner Ward Time to Think forum.

    Verbatim wording from the response

    “a. On the 13 July 2022, staff from Gardner Ward attended the “Time to Think” forum. There, the Trust’s Health, Safety and Security Planning Manager led the meeting and reinforced the correct escalation processes to use when a service user is missing.”

    Source location

    Response from East London NHS Foundation Trust
    Page 4 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Ratify the reviewed Missing and Absent Without Leave policy.

    Verbatim wording from the response

    “b. In June 2023, the Trust’s Missing and Absent without Leave policy was reviewed and it is now awaiting ratification.”

    Source location

    Response from East London NHS Foundation Trust
    Page 4 · response
    Published 22 June 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Engage senior-level Metropolitan Police partners to develop a coordinated response strategy for missing inpatients.

    Verbatim wording from the response

    “c. The Trust is now engaged at a senior level with the Metropolitan Police to develop a strategy around, “Right Care, Right Person” which is anticipated to lead to improvements in the coordination of response to missing inpatients by both organisations.”

    Source location

    Response from East London NHS Foundation Trust
    Page 4 · response
    Published 22 June 2023

    Open published response
  6. Manchester South

    AI-generated summary

    Rebecca Alice Fisher · 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

    Rebecca Alice Fisher was found deceased by her family on 15 April 2022 after being reported missing from a mental health ward following unescorted leave. A post-mortem found a fatal dose of drugs, including pregabalin. The principal concern was that Greater Manchester Police did not assess her as a high-risk missing person, resulting in delays to mobile telephone enquiries and specialised input; concerns also included gaps in staff understanding, documentation, information sharing, and the implementation of training and guidance.

    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 understanding of how to apply golden hour guidance and its required timescales

    Wider context from the report

    “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included: 1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return; 2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return; 3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and 4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit. The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them. Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest. ”

    Source location

    Rebecca Alice Fisher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unclear effectiveness of missing-person training in supporting high-risk assessments

    Wider context from the report

    “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included: 1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return; 2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return; 3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and 4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit. The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them. Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest. ”

    Source location

    Rebecca Alice Fisher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of understanding of how to access mobile phone data such as cell site data

    Wider context from the report

    “The inquest heard evidence that GMP have guidance to support officers in assessing risk and guiding actions when there is a missing person report. The evidence was that despite the existence of the policy/document the risk was not recognised as being high risk and the appropriate actions were not taken immediately. The evidence indicated that a number of factors were key in this failure to accurately assess the risk. This included: 1. Poor understanding by GMP staff of the fact that a patient detained on a voluntary basis in a mental health ward could still be high risk if they failed to return; 2. Lack of understanding by GMP staff that the use by mental health units of short periods away from the unit to support a patient’s recovery did not mean a patient could not be high risk if they did not return; 3. Lack of understanding by officers of how to apply the golden hour guidance and what was the expectation in terms of timeliness of undertaking the steps within the guidance coupled with a lack of understanding by some officers of the way/cost to GMP in accessing mobile phone data such as cell site; and 4. Poor quality documentation and information sharing between officers and supervision in relation to information from the family and the mental health unit. The inquest was told that GMP had rolled out an Aide Memoire system to try to embed greater consistency and understanding of the policy across GMP. The Aide Memoires were recognised as being an effective tool. However, there was no evidence available to assist in understanding if the Aide Memoires were being used effectively across the force and how GMP were measuring the implementation of them. Evidence was given to the inquest that GMP have introduced further training on missing persons. However, the effectiveness of that training was unclear given witnesses who had been on the training who gave evidence remained of the view that Rebecca was not a high-risk missing person despite all of the evidence available at the inquest. ”

    Source location

    Rebecca Alice Fisher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and disseminate a seven-minute briefing on mental-health terminology, associated risk, Golden Hour principles, communications data, costs, and Aide Memoire use.

    Verbatim wording from the response

    “GMP want to ensure that its staff and officers understand the terminology used by mental health services for voluntary mental health patients and for those who have unescorted leave. To address this, I have asked the Organisational Learning Development Group (OLDG) to produce a seven-minute briefing. A seven-minute briefing is widely used across organisations as research suggests that seven minutes is an ideal time span to concentrate and learning is more memorable, as it is simple and not clouded by other issues and pressures. It is delivered in a flow chart form, in person by supervisors. This format also allows the recipients to ask questions following the briefing to confirm their understanding.”

    Source location

    Response from Greater Manchester Police
    Page 2 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Circulate an interim memorandum to District Commanders for dissemination on mental-health terminology, risk, Golden Hour tasks, and mobile-phone data access.

    Verbatim wording from the response

    “Whilst this briefing package is being designed by the OLDG, GMP have, in the short term, circulated a memorandum to all District Commanders explaining the issues highlighted from this inquest and an explanation of the terminology used in mental health settings and previous misconception of risk. The notification also includes the information detailed within the response to point three below regarding golden hour tasks and a lack of understanding around the cost of accessing mobile phone data. The District Commanders will then disseminate this to their divisional supervisors and colleagues.”

    Source location

    Response from Greater Manchester Police
    Page 3 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the Missing from Home Policy wording on medium-risk Golden Hour timescales and consider clarification.

    Verbatim wording from the response

    “I have consulted with the MPSU, and they are going to consider this terminology and will be explaining it further to aid the officers understanding of what time frame this refers to.”

    Source location

    Response from Greater Manchester Police
    Page 3 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review whether further supervisor training on missing-person investigations, risk assessment, Golden Hour principles, communications data, and costs should be provided and determine its form.

    Verbatim wording from the response

    “To further address this issue across the organisation, the professional standards branch referred the matter to GMP’s training school, as it was recognised that supervisors who have been substantive for a long period of time may not have had any recent training or continuous professional development (CPD) with regards to investigating missing persons, Golden Hour tasks and risk assessments.”

    Source location

    Response from Greater Manchester Police
    Page 4 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Include Golden Hour guidance, cell-siting costs, family updates, and mental-health learning in operational briefings, then verify completion across districts.

    Verbatim wording from the response

    “The MPSU are also sending a notification to all operational Superintendents across the Force to state that the Golden Hour principles guidance is included within operational briefings alongside information regarding the cost of cell siting. The briefings will also include a reminder to operational Sergeants to keep the next of kin and family of the missing person updated, as per the concern raised in point four and include details of this case as an example of the importance of correct risk assessment and understanding of mental health terminology.”

    Source location

    Response from Greater Manchester Police
    Page 4 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Re-circulate the Missing from Home Policy 2022 and Aide Memoires through existing continuous professional development channels.

    Verbatim wording from the response

    “GMP are in the process of re-circulating the MFH Policy 2022 and Aide Memoires. These have already been shared through the CPD sessions that have been provided by the MPSU.”

    Source location

    Response from Greater Manchester Police
    Page 5 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Monitor completion of the actions identified in the Regulation 28 response through the Strategic Learning Board.

    Verbatim wording from the response

    “GMP is committed to constantly improving its response to Missing People. It is vital we learn lessons in such tragic cases. The strategic lead for safeguarding will put out immediate instructions to all district leads regarding the learning in this case and highlight the Golden Hour tasks that must be completed by all staff.”

    Source location

    Response from Greater Manchester Police
    Page 7 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Determine and implement a method to measure staff understanding and the briefing’s effectiveness.

    Verbatim wording from the response

    “I want to ensure that officers and staff understand the new information being presented to them within the briefing and that they can effectively apply this in their everyday role when investigating a missing person. To achieve this, the OLDG are currently exploring the most effective way to monitor their understanding. There are several options available which are being considered.”

    Source location

    Response from Greater Manchester Police
    Page 2 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate guidance that mobile-phone tracing and cell-site enquiries should be considered for medium- and high-risk missing persons, with rationale recorded when not pursued.

    Verbatim wording from the response

    “Specifically on the Stockport District, the Senior Leadership Team have already circulated a notification to all response supervisors to ensure that they are aware that cell citing, and mobile phone enquiries should be considered for medium risk missing persons, as well as high risk missing persons if relevant. If supervisors are not going to pursue an avenue of investigation, they should have a proper rationale to explain why it is not a proportionate enquiry and this should be recorded on the MFH report. This was also sent out to all District Commanders by the MPSU.”

    Source location

    Response from Greater Manchester Police
    Page 3 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create and distribute a communications-data guide covering Cycomms, mobile-phone enquiries, and access for medium- and high-risk missing persons.

    Verbatim wording from the response

    “Cycomms, cell siting, and mobile phone enquiries should be considered for medium and high-risk missing persons. A notification is also being sent out on the Organisation Learning Hub Top three bulletin June 2023 edition. Item one of the bulletin is regarding analysing communications data, and this covers the use of Cycomms and Mobile phone enquiries. A comprehensive guide has been created to address the learning around a lack of knowledge of this area. The bulletin will specifically detail that all communications data can be sought for medium and high risk missing, and a guide will direct officers on how to do this. The Organisation Learning Hub Top three bulletin goes to every member of staff and officer within GMP.”

    Source location

    Response from Greater Manchester Police
    Page 4 · response
    Published 17 May 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Cost to GMP must never justify not using mobile phone data for medium- or high-risk missing persons.

    Verbatim wording from the response

    “The cost to GMP to access mobile phone data and using cell siting should never be a reason as to why it is not used. The inquest highlighted a lack of understanding from some officers about this being a reason as to why GMP may not use cell siting. This is incorrect. Operational Superintendents will be informed of this via the notification from the Missing Person Safeguarding Unit and they will be asked to disseminate this information to their respective supervisors and teams across all districts to ensure that officers and staff are not considering this as a factor in their decision making. This would also ensure it is not cited as a reason to members of the public as to why GMP would not utilise mobile phone data.”

    Source location

    Response from Greater Manchester Police
    Page 4 · response
    Published 17 May 2023

    Open published response
  7. Swansea Neath Port Talbot

    AI-generated summary

    HANNAH WARREN · 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

    Hannah Warren was reported missing on 3 February 2016 after leaving London by car while expressing delusional thoughts, and her body was found in Port Talbot harbour the following morning. The inquest concluded that she died from drowning and a head injury. Concerns included shortcomings in the missing-person investigation, including delayed or insufficient use of the ANPR Bureau, communication failures, failure to contact family, and the use of a low-priority vehicle stop despite a medium risk assessment; the report also identified a lack of formal guidance, training, or protocols linking these systems.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of formal guidance, training, and protocols for correlating COMPACT risk assessments with ACT stop priority instructions

    Wider context from the report

    “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling; (2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle. (3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all. (4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT. (5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all. (6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically. ”

    Source location

    HANNAH WARREN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Mismatch between COMPACT risk assessments and ACT stop priority instructions

    Wider context from the report

    “(1) The evidence was clear that the most effective means of locating a missing person in Hannah’s position was to locate the vehicle in which it was assumed she was travelling; (2) There was an apparent mismatch between the COMPACT risk assessment for Hannah graded as “medium” and the LOW stop priority instruction on ACT in relation to her vehicle. (3) The evidence I and the jury heard was that there was no formal guidance, training, or protocols of any kind to assist with the dialogue between these two systems; instead, it was left to local custom and practice as to how to correlate any risk assessment with the priority instruction on the ACT, if at all. (4) The preponderance of the evidence was that the LOW stop instruction was inappropriate in this case, but I was not directed to any document or guidance that would have assisted those responsible at the time for selecting the correct priority on the ACT. (5) I have seen no evidence of any formal guidance, training, or protocols as to how these two critically important systems are meant to operate alongside one another safely, or at all. (6) This appears to be a national issue and is not related solely to the lack of any formal guidance, training, or protocols within the MPS specifically. ”

    Source location

    HANNAH WARREN · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Adapt national ACT and ReACT guidance into an MPS digital training package for frontline officers, covering risk alignment, priority grading, information and response requirements.

    Verbatim wording from the response

    “In November 2022, the College of Policing published the Information and Communications Technology (ICT) learning document “ACT and ReACT reports on PNC”. The document is a Home Office approved training tool aimed at frontline officers and supervisors, it details all aspects of the ACT process and responds to the failures and knowledge gaps identified during the inquest into Hannah’s death.”

    Source location

    Response from Metropolitan Police
    Page 4 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Introduce an SLA requiring inspector authorisation for low- and medium-priority ACT reports, 24-hour nominated contacts, and ownership of review and removal of obsolete entries.

    Verbatim wording from the response

    “To improve the accuracy of ACT report submissions, risk assessments and to ensure the ongoing management of the information held on the system, the MPS will shortly be introducing a new Service Level Agreement (SLA). This requires all low and medium priority ACT reports to have been authorised by an officer of at least the rank of inspector prior to submission (currently only high priority reports require a superintendent’s authority). In addition, all ACT reports must have nominated contact who is available 24hrs per day and suitably informed to provide updates and direction in the event of an activation. It will be the responsibility of the owning officer to review and remove entries from the system, if they are no longer required. The SLA is awaiting final approval, for publication in May 2023.”

    Source location

    Response from Metropolitan Police
    Page 5 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Individual police forces are responsible for operational missing-person investigations, while the College of Policing sets applicable standards and guidance.

    Verbatim wording from the response

    “The police investigation of a missing person report is an operational decision for individual police forces. The standards for these investigations for all forces in England and Wales are set by the College of Policing (henceforth ‘the College’) through their Authorised Professional Practice (APP). The College also issues guidance for police forces, including instructions on the use of ACT and REACT reports on PNC, the most recent version was published in November 2022.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Current police guidance is readily available and clearly sets out the actions officers should take in equivalent circumstances.

    Verbatim wording from the response

    “I am satisfied by the College that there is current police guidance on this matter which is readily available to forces; and clearly sets out the actions police officers should take were these circumstances to arise again. Specifically, the guidance states that missing persons fall into the category of ‘serious incidents’ and as such, at a minimum, a medium priority ACT report should have been put in place. The response from the College will set out further detail on the use of the ACT guidance.”

    Source location

    Response from Home Office
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Current ACT instructions require a STOP instruction for comparable missing-person cases and specify the action officers should take after an ANPR activation.

    Verbatim wording from the response

    “If a medium or high ACT report is added, there must be one of three words to start the report indicating the activity that a force should undertake if there is a relevant ANPR activation. These words are – Stop, Monitor or Assess (as described in the above extract).”

    Source location

    Response from National Police Chiefs' Council and College of Policing
    Page 2 · response
    Published 24 February 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational policing matters fall outside the Home Office’s authority, so it cannot intervene in police officers’ operational decisions.

    Verbatim wording from the response

    “The Home Office has no authority to intervene in operational policing matters. I cannot comment on the action and decisions taken by police officers in the course of their duties because operational matters are the responsibility of the Chief Officer of the force concerned. However, for the purposes of this response, my officials have consulted the College, the Metropolitan Police and the National Police Chiefs Council (NPCC) to seek assurance that the appropriate guidance is in place which addresses the concerns that you have raised.”

    Source location

    Response from Home Office
    Page 1 · response
    Published 24 February 2023

    Open published response
  8. Birmingham and Solihull

    AI-generated summary

    Leroy Patrick HAMILTON · Prevention of Future Deaths report

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

    Report summary

    Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.

    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 classify reported people as missing persons

    Wider context from the report

    “4. WMP Missing person investigations: The inquest heard how on 2 occasions (03/12/21 and 07/12/21) there was a failure to treat Mr Hamilton as a missing person when he was reported as missing. On both occasions he should have been treated as a high risk missing person. This raises a serious concern that staff do not understand when people should be classified as missing. Consideration should be given to ensuring staff properly understand how to assess if someone should be treated as a missing person and WMP should consider whether further training is required. ”

    Source location

    Leroy Patrick HAMILTON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review priority and internally generated log recording, conduct quality assurance audits, provide feedback, and deliver missing-person training to Force Contact staff.

    Verbatim wording from the response

    “Third, a full review has been conducted concerning the recording of priority response logs and internally generated logs. This involved work with Force Contact, Force Response and Locate. While this was part of a wider review process, it incorporated missing persons at the front-end reporting stage and quality assurance activity. This was carried out through weekly audits and weekly senior leadership meetings to discuss individual cases or themes where the correct risks had not been identified during call handling. To support this development, feedback was provided, improvements were noted, and training was delivered to Force Contact staff by experienced Locate supervisors.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create a Support Desk with continuity of staffing, increased supervisory oversight, focused Locate training and ongoing support for service calls including missing persons.

    Verbatim wording from the response

    “Fourth, following the full review, a ‘Support Desk’ was created. This entailed continuity of staff dealing with calls for service – including missing persons – with an increased number of supervisors in post to review and scrutinise the work of support staff. This provides a focused training opportunity for Locate staff, as well as on-going support.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Consider establishing a specialist Force Contact desk for complex calls, including missing-person reports, with dedicated support and training.

    Verbatim wording from the response

    “Fifth, WMP is considering whether to establish a specialist desk within Force Contact that will entail the same staff dealing with more complex calls, such as missing persons. This will ensure that Force Contact staff receive the right support and training as a continuation of the ‘Support Desk’.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Conduct detailed audits of missing-person call handling, risk assessment and compliance with the 12 key questions.

    Verbatim wording from the response

    “Sixth, detailed audits have been carried out which reveal a marked improvement from 2020 to 2022. While there is still work to do, the audit revealed 90% compliance with the ‘12 key questions’ and 100% of call calls audited accurately recorded, and correctly applied, the appropriate risk grading. Just 2% of all incidents audited in 2022 had no clear full risk assessment, compared to 66% in 2020.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Run a pilot introducing early Inspector review, central control and progression for missing-person investigations, with escalation and ongoing initial-stage management.

    Verbatim wording from the response

    “Seventh, a pilot scheme was recently implemented, led by the Chief Inspector Missing Lead for Force Response, which amends the response to missing person reports. This pilot scheme entails an early Inspector review to ensure that the right response is in place from the outset, that risk is correctly identified, and that there is ongoing management throughout the initial stages of investigation including any required escalation. The pilot scheme creates a central point of control and progression for all missing person investigations. This is an on-going project and a further update concerning the conclusion of the pilot scheme is awaited.”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a Locate learning portal with a missing-person toolkit and partner-agency information in consultation with stakeholders.

    Verbatim wording from the response

    “Eighth, the Locate learning portal is in the final stages of design. This resource will adopt a new approach to learning which will provide staff with a toolkit for their interactions with missing persons. The content is being produced in consultation with key stakeholders and will be extended to add partner information where appropriate. Relatedly, an online missing person package is currently available on WMP systems, which is regularly refreshed. Officers are requested to complete the package, which supports them in identifying missing persons and understanding primary actions to be taken. As of October 2022, more than”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Maintain and refresh the online missing-person training package, requiring officer completion and embedding it in student officer training.

    Verbatim wording from the response

    “Eighth, the Locate learning portal is in the final stages of design. This resource will adopt a new approach to learning which will provide staff with a toolkit for their interactions with missing persons. The content is being produced in consultation with key stakeholders and will be extended to add partner information where appropriate. Relatedly, an online missing person package is currently available on WMP systems, which is regularly refreshed. Officers are requested to complete the package, which supports them in identifying missing persons and understanding primary actions to be taken. As of October 2022, more than”

    Source location

    Response from West Midlands Police
    Page 3 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Upgrade the COMPACT missing-person recording system to improve prevention interviews, risk documentation, information sharing and data insight.

    Verbatim wording from the response

    “Ninth, WMP has completed an upgrade of its missing persons recording system (COMPACT). The main benefit of this upgrade is to ensure that the police prevention interview is more detailed, and that relevant information is passed to other agencies in order to support vulnerable persons in a holistic way. The upgrade to COMPACT prompts officers to consider things such as presentation and wider risk. This will improve the overall approach missing persons and ensure that information about history and risk are properly documented and accessible. Another beneficial feature of the upgrade is that it allows improved data insight into high demand missing locations and persons. This data will be used to understand where action and support is needed to support missing persons and reduce future threat, risk and harm.”

    Source location

    Response from West Midlands Police
    Page 4 · response
    Published 16 January 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Local policing arrangements are outside the Health Minister’s remit.

    Verbatim wording from the response

    “The report raises concerns over numbers of inpatient mental health and psychiatric decision unit beds and arrangements for informal missing patients. It also raises concerns about local policing arrangements and you will understand that these are outside of my remit as a Health Minister.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 January 2023

    Open published response
  9. Dorset

    AI-generated summary

    Gaia Kima Pope-Sutherland · 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

    Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.

    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

    Ambiguity in Dorset Police policies for welfare concerns, missing persons, and call handling, grading and deployment

    Wider context from the report

    “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of staff knowledge of Dorset Police welfare, missing persons, and call handling policies

    Wider context from the report

    “iv. As per paragraphs 1(v-vi) above, there could be future deaths that occur as a result of current Dorset Police policies around concern for welfare reports, missing persons reports, and the call handling, grading and deployment of resources and I request that consideration is given to a thorough review of these policies to reduce ambiguity and prevent future deaths. I would further request that consideration is given to providing a comprehensive training package to all Police Officers and control room staff within Dorset Police, around the missing persons policy, concern for welfare policy, and for control room staff only, the call handling, grading and deployment policy. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Embed the adopted missing-person policy changes into working practice.

    Verbatim wording from the response

    “The latest review of the missing person policy was in the process of being finalised during Gaia’s inquest. I enclose a copy of the finalised policy, which is now adopted, and work is ongoing to embed the changes in working practice. I highlight a few aspects of the updated policy that were relevant to the matters explored in the course of Gaia’s inquest:”

    Source location

    Response from Dorset Police
    Page 2 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review the concern-for-welfare policy to incorporate current physical and mental ill-health trends and professional guidance.

    Verbatim wording from the response

    “The Dorset Police concern for welfare policy is designed, in consultation with partner agencies, to ensure that the public get the right service to meet their specific needs at the first point of contact. The current version is subject to a review led by the Prevention Department to capture the latest physical and mental ill health trends and guidance from key professionals. The initial draft of the policy is close to completion.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement revised call-handling, deployment and grading policies with risk assessment and performance monitoring.

    Verbatim wording from the response

    “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Evaluate how revised policies affect deployment decisions and complete the commissioned external audit.

    Verbatim wording from the response

    “The Organisation reviewed and updated the call handling, deployment and grading policy in 2021 and implemented changes in March 2022. The Deployment Policy has been recently reviewed in line with national guidance to ensure that each public contact is risk assessed to inform the appropriate police response. The revised grading of incidents is now a key performance measure with regular reviews and evaluation to ensure compliance. As part of the implementation process, we have now moved to the evaluation stage to understand how the changes in the policy have translated into deployment decision making. The Organisation has commissioned an external audit conducted by the South West Audit Partnership which has been taking place over the summer. A full report is due this Autumn which will inform ongoing developments.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver Vulnerability 4 training on welfare, missing-person and deployment policies to relevant staff and officers.

    Verbatim wording from the response

    “The next stage of the Vulnerability Programme is the ‘Vulnerability 4’ training package, scheduled for delivery between January and April 2023. The Vulnerability 4 training will include updates on the concern for welfare, missing people and the call handling, grading and deployment policies. It will be provided to police officers and staff, including control room call handlers, senior officers up to the rank of Chief Inspector and role-specific training to the ranks above Chief Inspector.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Disseminate the updated missing-person policy and provide recurring contact-centre refresher training.

    Verbatim wording from the response

    “In the meantime, the updated version of the missing person policy has been disseminated locally through Commanders and Inspectors, who are cascading the learning to frontline officers and ensuring the policy has been read and understood. Force Contact Centre training on the new missing person policy begins from the 19th September on the current 10 week cycle for all staff. Every training cycle will include refresher training on missing people and concern for welfare matters for the foreseeable future.”

    Source location

    Response from Dorset Police
    Page 3 · response
    Published 28 September 2022

    Open published response
  10. Surrey

    AI-generated summary

    William SAVORY · 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

    William Savory, a 31-year-old man, was found deceased on 27 January 2020 after leaving a psychiatric hospital and not returning at the agreed time. His death was due to acute fatal alcohol toxicity after drinking a significant amount of alcohol. The Coroner was concerned that not all staff were aware that missing person procedures should be commenced immediately.

    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 staff awareness of the requirement to commence missing person procedures immediately

    Wider context from the report

    “SABP’s written policies require staff to commence missing person procedures immediately, yet the Coroner is concerned that not all staff are aware of this requirement. The Coroner therefore invites SABP to consider additional training or other measures to raise awareness of this requirement amongst all levels of staff including Health Care Assistants. ”

    Source location

    William SAVORY · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
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Data last updated 7 September 2026